The Agency for Healthcare Research and Quality Hospital Labs Studying Patient Safety Consortium and Error Reduction

In 2002, the Agency for Healthcare Research and Quality funded a consortium of hospital laboratories to study errors in the anatomic pathology diagnostic testing pathway. Currently, 9 laboratories are consortium members and share error data, perform root cause analysis, and design and implement error reduction initiatives. These laboratories have established baseline error frequencies and determined the causes of diagnostic, sampling, identification, and reporting errors. These laboratories have shown that interpretive variability is a major impediment to error reduction. During the last several years, error-reduction interventions have been attempted in many areas of anatomic pathology. Interventions such as double-slide viewing and process redesign have been shown to reduce significantly error proportions.