Learning to improve safety: false-positive pathology report results in wrongful surgery.

Background: A patient experienced a wrongful surgical resection, specifically, a radical retropubic prostatectomy because of a false-positive pathology report.

Findings From The Root Cause Analysis (rca): The RCA team identified three antecedent events that contributed to this medical error: (1) a second (concurring) pathologist did not provide a written opinion, (2) a single pathologist who reviewed and signed the final report, and (3) a pathologist who did not review the case and reconfirm the diagnosis immediately prior to the surgical resection.

Recommendations: The RCA team recommended that the concurring pathologist write his or her diagnostic findings on the referral form, two pathologists review and sign the final typed report, and a pathologist rereview the slides on the business day prior to a surgical resection.