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A human factor event-based learning assessment tool for assessment of errors and diagnostic accuracy in histopathology and cytopathology

Lookup NU author(s): Dr Sarah Johnson


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© 2020 BMJ Publishing Group. All rights reserved.This review article summarises systems for categorisation of diagnostic errors in pathology and cytology with regard to diagnostic accuracy and the published information on human factors (HFs) in pathology to date. A 12-point event-based checklist for errors of diagnostic accuracy in histopathology and cytopathology is proposed derived from Dupont's € Dirty Dozen' HF checklist, as used in the aerospace industry for aircraft maintenance. This HF checklist comprises 12 HFs; (1) Failure of communication. (2) Complacency. (3) Lack of knowledge. (4) Distractions. (5) Lack of teamwork. (6) Fatigue. (7) Lack of resources. (8) Pressure. (9) Lack of assertiveness. (10) Stress. (11) Norms. (12) Lack of awareness. The accompanying article explains practical examples of how each of these 12 HFs may cause errors in diagnostic accuracy in pathology. This checklist could be used as a template for analysis of accuracy and risk of diagnostic error in pathology either retrospectively € after the event' or prospectively at the time of diagnosis. There is a need for further evaluation and validation of this proposed 12-point HF checklist and similar systems for categorisation of diagnostic errors and diagnostic accuracy in pathology based on HF principles.

Publication metadata

Author(s): Poller DN, Bongiovanni M, Cochand-Priollet B, Johnson SJ, Perez-Machado M

Publication type: Article

Publication status: Published

Journal: Journal of Clinical Pathology

Year: 2020

Volume: 73

Issue: 10

Pages: 681-685

Online publication date: 29/06/2020

Acceptance date: 30/03/2020

ISSN (print): 0021-9746

ISSN (electronic): 1472-4146

Publisher: BMJ Publishing Group


DOI: 10.1136/jclinpath-2020-206538

PubMed id: 32601067


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