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O erro em Anatomia Patológica : análise de 2884 exames histopatológicos do Hospital Prof. Doutor Fernando Fonseca EPE
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RESUMO - O erro médico é considerado a terceira causa de morte nos Estados Unidos
da América. Em Portugal, a incidência de eventos adversos identificada é de 11,1%.
Também em anatomia patológica o erro é incontornável, variando a frequência
reportada na literatura entre 0,5% e 43%. O único trabalho nesta área realizado em
Portugal incidiu apenas nos erros na fase pré-analítica.
O objetivo geral deste estudo foi determinar a prevalência de erros e os
fatores associados ao erro em exames histopatológicos no serviço de anatomia
patológica do Hospital Prof. Doutor Fernando Fonseca, no ano de 2014.
Foram avaliados 2884 exames (2184 biopsias e 700 peças operatórias). A
prevalência de erros detetada foi de 14,0% (n=404), com um intervalo de confiança
a 95% de 12,9% a 15,1%. O tipo de erro mais prevalente foi o erro na interpretação
(36,1% dos erros), dos quais 18,6% tiveram consequências para o doente. Da
análise multivariável salienta-se a associação do erro com a patologia neoplásica, a
ausência de história clínica na requisição, a maior experiência do patologista, a
existência de relatório sinótico e o tempo de resposta mais curto.
Este é o primeiro estudo deste tipo em Portugal e permitiu determinar a
prevalência e caracterizar os erros em exames histopatológicos num serviço de
anatomia patológica. A prevalência de erros encontrada é sobreponível às
publicadas em estudos semelhantes, identificando pela primeira vez associação do
erro com falhas de informação na requisição, a maior experiência do patologista e
tempos de resposta mais curtos.
ABSTRACT - Medical error is considered the third leading cause of death in the United States of America. In Portugal, the reported incidence of adverse events is 11,1%. In anatomic pathology the error is also present, and its reported frequency diverges between 0,5% and 43%. The single published Portuguese investigation in this field refers only to pre-analytical errors. The aims of this study were to determine the error prevalence and the factors related to error in histopathology specimens in the surgical pathology department of Hospital Prof. Doutor Fernando Fonseca, during 2014. In this investigation, 2884 histopathology cases were reviewed. The prevalence of error was 14,0% (n=404), with the 95% confidence interval range between 12,9% and 15,1%. The most prevalent error subtype was the error in interpretation, 18,6% of which had clinical consequences to the patient. In the multivariate analysis, a statistically significant association was detected between error occurrence and neoplastic pathology, the absence of clinical information in the exam request form, more years of practice of the pathologist, the existence of a synoptic report and a shorter turnaround time. This is the first study of its kind made in Portugal and allowed to determine the prevalence and characteristics of error in a surgical pathology department. The prevalence of error found is similar to those reported in literature. It’s reported for the first time an association between the occurrence of error and absent clinical information in the request form, more years of practice of the pathologist and a shorter turnaround time.
ABSTRACT - Medical error is considered the third leading cause of death in the United States of America. In Portugal, the reported incidence of adverse events is 11,1%. In anatomic pathology the error is also present, and its reported frequency diverges between 0,5% and 43%. The single published Portuguese investigation in this field refers only to pre-analytical errors. The aims of this study were to determine the error prevalence and the factors related to error in histopathology specimens in the surgical pathology department of Hospital Prof. Doutor Fernando Fonseca, during 2014. In this investigation, 2884 histopathology cases were reviewed. The prevalence of error was 14,0% (n=404), with the 95% confidence interval range between 12,9% and 15,1%. The most prevalent error subtype was the error in interpretation, 18,6% of which had clinical consequences to the patient. In the multivariate analysis, a statistically significant association was detected between error occurrence and neoplastic pathology, the absence of clinical information in the exam request form, more years of practice of the pathologist, the existence of a synoptic report and a shorter turnaround time. This is the first study of its kind made in Portugal and allowed to determine the prevalence and characteristics of error in a surgical pathology department. The prevalence of error found is similar to those reported in literature. It’s reported for the first time an association between the occurrence of error and absent clinical information in the request form, more years of practice of the pathologist and a shorter turnaround time.
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Prevalência de erros Anatomia Patológica Segurança do Doente Qualidade em Saúde Error prevalence Anatomic Pathology Patient Safety Quality in Health