Interpretive Diagnostic Error Reduction in Surgical Pathology and Cytology
Thu, 14 May 2015

The College of American Pathologists (CAP) and the Association of Directors of Anatomic Pathology (ADASP) are pleased to announce the release of a new evidence-based guideline:

Interpretive Diagnostic Error Reduction in Surgical Pathology and Cytology

This guideline, now available as an early online edition of Archives of Pathology & Laboratory Medicine, includes five recommendations and expert consensus statements to assist anatomic pathologists to implement added quality measures for review of surgical pathology and cytology cases. These recommendations call for anatomic pathologists to develop procedures for review and to perform the reviews in a timely manner to positively impact patient care. In addition, the guideline recommends that pathologists document and continuously monitor these procedures relevant to their practice setting, as well as take steps to improve agreement in cases where agreement is lacking. Adoption of secondary and timely case reviews will help detect and prevent diagnostic interpretive errors, leading to more accurate diagnoses and improved patient care.

We encourage pathologists to implement the new guideline at their institutions and into their practices to help ensure accurate diagnoses and improve patient care.

The CAP Pathology and Laboratory Quality Center and ADASP provided the forum for the guideline development and convened an expert panel of pathologists to address the overarching question “What are the most effective ways to reduce interpretive diagnostic errors in Anatomic Pathology?” The key questions the panel addressed were:

  1. Does targeted review (either done at analytic or post-analytic phase) of surgical pathology or cytology cases (slides and/or reports) reduce the error rate (often measured as amended reports) or increase the rate of interpretive error detection compared to no review, random review or usual review procedures?
  2. What methods of selecting cases for review have been shown to increase/decrease the rate of interpretive error detection compared to no review, random review, or usual review procedures?

The expert panel conducted a systematic review of more than 137 publications covering almost 823 citations in the context of open comment feedback, quality of evidence, and their own expert judgments in the field of surgical pathology and cytology.

The CAP offers tools and resources, including a summary of the recommendations, and frequently asked questions (FAQs), an infographic, and two videos (CAP/ADASP Offer New Guideline to Improve Laboratory Testing and New CAP/ADASP Guideline: Benefit to Pathologists and Patient Care) for further implementation and understanding. The two organizations plan to update the guideline as new evidence becomes available.

We invite you to communicate the news of the guideline to your members.  Please feel free to contact us at if you have any questions or would like additional information.

Lisa A. Fatheree, SCT(ASCP)
Director, Pathology and Laboratory Quality Center
College of American Pathologists