Dermatology Clinic Turns to Aviation-Style Safety Reporting After Five Years of Paper Forms

When a patient walks into a dermatology clinic for a routine biopsy, the last thing on their mind is whether the specimen vial will reach the pathology laboratory with the correct label attached. Yet a new five-year analysis from an academic dermatology department in Rhode Island reveals that precisely this kind of error—lost or mislabeled tissue samples—ranks among the most frequently reported safety incidents in outpatient skin care. The study, published in Archives of Dermatological Research, offers a rare longitudinal window into how adverse events unfold in a specialty that has long been understudied by patient safety researchers, and it documents the messy, human reality of trying to capture medical errors on paper forms.

The research team, led by Alyssa M. Iurillo of NewYork-Presbyterian Brooklyn Methodist/Weill Cornell Medical Center together with colleagues at The Warren Alpert Medical School of Brown University, conducted a retrospective cross-sectional quality improvement study covering the period from 2017 to 2022. Their dataset consisted of department-generated paper-based incident reports, which the investigators systematically reviewed to determine the frequency, type, severity, and origin of each recorded safety event. This kind of single-institution, multi-year analysis is uncommon in dermatology, a field where most safety literature has focused on surgical specialties or inpatient hospital wards rather than the fast-paced environment of outpatient clinics where procedures such as shave biopsies, excisions, and Mohs micrographic surgery are performed daily.

What the researchers found was a modest but revealing tally: 78 safety events were reported across the five-year study window. Three categories dominated the record. Pathology-related errors, including specimens that were lost, mislabeled, or otherwise compromised between the exam room and the laboratory, formed the largest group. Needlestick injuries came next, a hazard familiar to any clinic that handles sharps, followed by non-needlestick injuries. The distribution matters because each category points to a different failure mode in the system—specimen handling reflects breakdowns in chain-of-custody and labeling workflows, while sharps injuries implicate technique, disposal infrastructure, and moment-to-moment clinician attention during procedures.

The severity profile, however, offers genuine reassurance. The vast majority of reported events, 60.30 percent, were classified as ‘no harm,’ meaning the error reached the patient or the diagnostic pathway without causing injury. No severe harm events and no deaths appeared anywhere in the dataset. But the researchers caution against complacency. The prevalence of low and moderate harm events—including specimen mislabeling episodes and situations requiring repeat biopsies—signals ongoing vulnerabilities that could escalate under different circumstances. A mislabeled specimen, for example, carries the potential for a devastating diagnostic error: a malignant lesion attributed to the wrong patient, or a benign result attached to a cancerous sample. The literature on lost pathology specimens, including prior work in dermatologic surgery, has documented that such losses occur at measurable rates even in well-run practices, making the Rhode Island findings consistent with a broader, systemic pattern rather than an isolated institutional failure.

Perhaps the most striking findings concern who reported the events and when. Attendings and medical assistants submitted the majority of the 78 reports, while dermatology residents contributed disproportionately few. This disparity is a well-recognized phenomenon in graduate medical education research. Studies of adverse event reporting across specialties have repeatedly found that trainees, despite being front-line witnesses to errors, underreport at higher rates than their supervising physicians and nursing staff. The authors suggest that educational or logistical barriers may explain the pattern—residents rotate through multiple sites, may be uncertain about the reporting workflow, or may fear that filing a report could reflect poorly on their evaluations. Prior research published in the Journal of Patient Safety has argued that harnessing residents as a reporting resource, rather than treating them as passive participants in safety culture, represents an untapped opportunity for departments seeking to improve error detection.

The temporal trend in the data tells its own story. Reported events peaked in 2019 and then declined during the COVID-19 pandemic, a pattern the authors attribute to broader disruptions in healthcare delivery. The pandemic dramatically reduced in-person outpatient visits as clinics shifted to telehealth and deferred elective procedures, which mechanically reduced the number of opportunities for biopsy-related and sharps-related events. At the same time, pandemic-era pressures are known to have strained reporting systems across medicine, as staff contended with surging workloads, redeployment, and infection control protocols that pushed routine quality activities to the margins. The decline in reports during this period therefore likely reflects both fewer events and diminished reporting activity—a distinction that paper-based systems, with no automated capture, cannot easily untangle.

Underreporting emerges as the study’s central concern. The authors identify several systemic limitations baked into the old paper-based workflow: the physical difficulty of accessing reporting forms, the absence of structured feedback to reporters after a submission, and fear of repercussions. Each of these barriers has been documented extensively in the patient safety literature. National surveys of US hospitals have shown that reporting practices vary widely and that voluntary systems capture only a fraction of the errors that actually occur. Classic studies comparing physician and nurse reporting behavior found that clinicians often file reports only for events they perceive as serious, leaving near misses—the early-warning signals that safety scientists value most—largely invisible. When the reporting medium itself is a paper form stored somewhere in the clinic, the friction of filing becomes a silent filter that shapes the entire dataset.

The department’s response to these findings is arguably the most newsworthy element of the study. In 2023, the practice transitioned to an electronic adverse event reporting system featuring structured dropdown categories and automated data capture. Notably, the design drew on safety protocols from commercial aviation, an industry whose safety management systems—codified in standards from the International Civil Aviation Organization and the Federal Aviation Administration—prioritize accessibility, standardization, and a non-punitive reporting environment. Aviation’s approach, exemplified by systems like NASA’s Aviation Safety Reporting System, rests on a simple premise: people will only disclose mistakes freely if disclosure cannot be used against them. Translating that philosophy into a dermatology clinic means making the reporting interface fast enough to use between patients, standardizing the vocabulary of incident categories so that trends can be analyzed quantitatively, and guaranteeing that reports feed back into visible system improvements rather than disappearing into a filing cabinet.

The technical advantages of the electronic system extend beyond convenience. Automated data capture eliminates the transcription errors and incomplete fields that plague paper forms, while structured dropdowns force consistent categorization, enabling statistical comparison across years, roles, and event types. The system also facilitates more efficient tracking, analysis, and follow-up of individual events, closing the feedback loop that the authors identified as a key deficiency of the paper era. The researchers suggest that their digital framework may serve as a template for other outpatient specialty clinics, which face a distinct safety landscape compared to hospitals: high procedure volumes, rapid patient turnover, specimen transport dependencies, and smaller staff pools in which each individual’s reporting behavior carries proportionally greater weight.

The broader significance of the study lies in its demonstration that dermatology-specific safety reporting deserves the same rigor that has transformed hospital inpatient safety over the past two decades. With 78 events over five years at a single academic practice, the absolute numbers are small, but the authors argue the insights lay the groundwork for more robust quality improvement initiatives both locally and across institutional networks. The call to action is directed at every role in the clinic—attendings, medical assistants, and residents alike—because a safety culture in which only some staff report is a safety culture flying with instruments covered. As outpatient care continues to expand and procedures migrate away from hospitals, the lessons from this Rhode Island department suggest that the tools of aviation, applied thoughtfully to the biopsy tray and the specimen vial, may help medicine’s most visible specialty see its own blind spots more clearly.

Subject of Research: Adverse event reporting trends and barriers in an academic dermatology practice

Article Title: Safety events at a dermatology practice: a retrospective cross-sectional analysis of safety event reporting trends and barriers

Article References: Safety events at a dermatology practice: a retrospective cross-sectional analysis of safety event reporting trends and barriers. (n.d.). https://doi.org/10.1007/s00403-026-04992-y

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04992-y

Keywords: patient safety, dermatology, adverse events, specimen labeling errors, needlestick injuries, incident reporting, quality improvement, electronic reporting system, underreporting, COVID-19, aviation safety model, outpatient care