Incidence of missing pathology specimens in dermatology

Abstract

Background: Occasionally specimen containers are received in the dermatopathology laboratory without an accompanying specimen. The consequences in this scenario can range from delay in care and inconvenience to patients to increased morbidity and even mortality. Data regarding incidence and associated characteristics of missing specimens are scant.Methods: Over a 10-year period (7 January 2010 to 7 January 2020) all cases with a missing specimen in a single academic dermatopathology laboratory and a single dermatopathology practice embedded within a dermatology practice were reviewed.Results: Out of 270,754 specimens received, 83 empty specimen containers were identified for an incidence of 0.031%. There were 14 (0.005%) cases in which patients had a separate procedure and a second container with both specimens in it accompanying the empty container. The most common missing specimen-generating procedures were shave biopsies (51%) with most common clinical diagnosis being unspecified (30%). The most common specimen location from the 97 total specimen bottles containing either zero or two specimens was head/neck (53%). Although no further procedures were performed after the specimen was lost for 48% of cases, re-biopsy occurred for 28%.Conclusions: Failure to insert specimens into the correct container is rare, but represents a potential significant negative event where vigilance and improvement is required.

Errors encountered in the diagnostic pathway: A prospective single‐institution study

“…Of note, we reported six incidents of empty bottle specimens out of 25 662 total specimens. One study reported a comparable 83 empty bottle specimens from 270 754 specimens at a single academic dermatopathology laboratory 2 . Empty bottle specimens happen rarely but can lead to significant patient inconvenience and delays in care.…”

“…Previous studies investigating dermatopathology errors have focused on specific aspects of the diagnostic pathway, such as amendment rates, data entry errors, or missing pathology specimens. [2][3][4] The impact of medical errors is profound, costing the healthcare system an estimated $4-$20 billion annually, and is a leading cause of death in the United States. [5][6][7] A study of malpractice claims in pathology shows that while pathology claim frequency is low, the claim severity is high, especially in melanoma misdiagnoses.…”

“…There is a paucity of literature on errors encountered in dermatopathology. Previous studies investigating dermatopathology errors have focused on specific aspects of the diagnostic pathway, such as amendment rates, data entry errors, or missing pathology specimens 2–4 …”