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Improving patient safety by examining pathology errors

      In 1999, the Institute of Medicine (IOM) released a report on the scope of medical error in the United States and on recommendations for reducing medical error and improving patient safety [
      ]. The IOM defined medical error as the failure to complete a planned action as intended or the use of the wrong plan to achieve an aim [
      ]. Medical errors permeate all levels of patient care, and the IOM report has resulted in the greater recognition of error and an increased focus on reporting and reducing errors [
      • Becher E.C.
      • Chassin M.R.
      Improving the quality of health care: who will lead?.
      ,
      • Ioannidis J.P.A.
      • Lau J.
      Evidence on interventions to reduce medical errors. An overview and recommendations for future research.
      ,
      • Joint Commission on Accreditation of Healthcare Organizations
      Sentinel events: approaches to error reduction and prevention.
      ,
      • Kizer K.W.
      Patient safety: a call to action: a consensus statement from the national quality forum.
      ,
      • Meyer G.
      • Foater N.
      • Christrup S.
      • Eisenberg J.
      Setting a research agenda for medical errors and patient safety.
      ,
      • Meyer G.
      • Lewin D.I.
      • Eisenberg J.M.
      To err is preventable: medical errors and academic medicine.
      ]. Some error types, such as medication errors, have been well documented and better addressed than other error types [
      • Leape L.L.
      • Kabcenell A.I.
      • Gandhi T.K.
      • Carver P.
      • Nolan T.W.
      • Berwick D.M.
      Reducing adverse drug events: lessons from a breakthrough series collaborative.
      ,
      • Silver M.P.
      • Antonow J.A.
      Reducing medication errors in hospitals: a peer review organization collaboration.
      ,
      • Stump L.S.
      Re-engineering the medication error-reporting process: removing the blame and improving the system.
      ]. Diagnostic error has been less extensively studied, particularly in regard to anatomic pathology practice.
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