Patient Safety and Informing
  Patients of Pathology Errors

Policy Synopsis

The College of American Pathologists believes that it is a fundamental ethical requirement that a physician should deal honestly and openly with patients. Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician’s mistake or judgment. In these situations the physician is ethically required to inform the patient of the facts necessary to ensure understanding of what has occurred.

Policy

The College of American Pathologists believes that it is a fundamental ethical requirement that a physician should deal honestly and openly with patients. Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician’s mistake or judgment. In these situations the physician is ethically required to inform the patient of the facts necessary to ensure understanding of what has occurred. The following points will guide the pathologist in this responsibility.

1. Significant errors are considered those that have had a negative impact upon the prospective health or management of the patient. When such a error contributed to the health care injury, that error must be reported to the patient in coordination with the ordering provider and within a manner consistent with the organization's disclosure policies as well as local, state and federal regulations.
2. All inaccuracies in the medical record should be documented and communicated at the time the inaccuracy becomes known. The correct test result or diagnosis should be made clear in an amended or corrected report as soon as possible. The reason that the original result was reported incorrectly (i.e., due to error or other reason) may not be known and need not be reported in the medical record.
3. When an incorrect result or diagnosis causes material injury to a patient, the correct result/diagnosis and the fact that the result has been changed must also be reported to the patient. For an inaccuracy caused by or directly involving a pathologist, the pathologist involved in the case should discuss the matter with the physician who ordered the pathology consultation. The two physicians should jointly determine how best to communicate the result to the patient.

Revision History

Adopted August 2004