PT  - JOURNAL ARTICLE
AU  - David Nigel Poller
AU  - Massimo Bongiovanni
AU  - Beatrix Cochand-Priollet
AU  - Sarah J Johnson
AU  - Miguel Perez-Machado
TI  - A human factor event-based learning assessment tool for assessment of errors and diagnostic accuracy in histopathology and cytopathology
AID  - 10.1136/jclinpath-2020-206538
DP  - 2020 Oct 01
TA  - Journal of Clinical Pathology
PG  - 681--685
VI  - 73
IP  - 10
4099  - http://jcp.bmj.com/content/73/10/681.short
4100  - http://jcp.bmj.com/content/73/10/681.full
SO  - J Clin Pathol2020 Oct 01; 73
AB  - 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.