Error and Error Reduction in Pathology

Abstract

CONTEXT: Since publication of the Institute of Medicine's report on medical error in late 1999, there has been widespread interest in improving patient safety and in error reduction in all disciplines of medicine. In fields other than medicine, considerable knowledge has been obtained concerning error and error reduction. This body of knowledge can be successfully applied to pathology in order to make the specialty safer and less error prone. OBJECTIVES: To review the fundamental conclusions of the Institute of Medicine's report on medical error, to provide a taxonomy of error that can be adapted to pathology, to provide a framework for studying and analyzing error in pathology, to contrast different approaches to error, and to explain the concept of a culture of safety. DESIGN: Review of pertinent literature, analysis of concepts of error reduction and safety used in other disciplines, analysis of pathology workflow, and adaptation of safety practices to the practice of pathology. RESULTS: A taxonomy for error is described and adapted to pathology, a framework for error in the specialty is described, and characteristics of a culture of safety for pathology are proposed. CONCLUSIONS: Fundamental concepts of error reduction and safety improvement exist in other disciplines and can successfully be adapted to pathology.