Multi-institutional database of anatomic pathology errors

In 2002, the Agency for Healthcare Research and Quality funded a consortium of institutions to study the current state of anatomic pathology error. This consortium designed and constructed an anatomic pathology error database that was used to benchmark institutional frequencies, causes and outcomes of error. The aggregated and institutional data showed high variability in practice and that anatomic pathology errors generally were caused by multiple system failures, often occurring in the pre-analytic and post-analytic testing phases. The consortium used these data to design error reduction initiatives that were implemented in practices. Institutional monitoring of error data following implementation often resulted in considerable error reduction. This model of database use and improvement is demonstrated using several examples.