Amendments in Non-Gynecologic Cytopathology Reports: An Institutional Experience of Statistics, Root Causes and Recommendations

Summary: Background: Amendments in pathology are typically issued when an error is identified that warrants correction. We aimed to evaluate the root causes, frequency, types of errors and time to amendment (TTA) in non-gynecologic (N-GYN) cytopathology. Design: Amended N-GYN cytopathology reports were retrieved from our online database (REDCap) from 3.5 years. The reports were organized by specimen type, error type (the reason for the correction), level of error and TTA. Amendments were categorized by the authors by the level of error as: “minor correction, no clinical impact”, “moderate correction, potential to alter the clinical course”, and “major correction, likely to change clinical course and outcome”. The data was statistically analyzed and reviewed. Results: There were 40,806 N-GYN cytology cases during the study period. 116 amendments were issued for 114 cases (0.279%). Fifteen (13%) cases were due to non-pathologist error (eg. accessioning). There were 88 (76%) amendments due to minor errors, while 11 (9%) were moderate and 2 (2%) were major errors. The most common cause of minor errors were clerical (75%). Moderate errors were caused by diagnostic and ancillary test interpretation errors (5 each or 45% each) and 1 FNA site error. The major errors include a false positive lung FNA, and a false negative pleural fluid flow cytometry. In general, diagnostic errors comprised of 17 cases (15%), of which 6 (5%) were moderate errors. 30 (26%) cases were amended due to errors associated with flow cytometry or molecular reporting, 27 (90%) were minor and 3 (10%) were moderate or major. Thyroid FNAs (23%) were the predominant of the amended cases. The median overall TTA was 3 days; 2 days for minor errors and 32 days for moderate errors. The TTA for the major errors were 1 and 80 days. 28% of errors (33) were corrected within the day of sign out. Conclusion: Amendments to pathology reports are vital for maintaining accuracy. Major and moderate errors, though rare, can lead to negative clinical outcomes if discovered late, while minor errors are more common and often detected soon after sign-out. To reduce errors, improve report accuracy and enhance outcomes, we recommend standardizing reporting formats for clarity, providing training for cytopathology staff on best practices, leveraging automated systems and electronic record integration, conducting peer reviews and robust QA programs to identify patterns of mistakes and encourage communication among clinical teams for timely discussions on findings. Sigfred Lajara, N. Paul Ohori, Jon M Davison, and Samer N Khader