Improving the quality of cytology diagnosis

Root cause analysis for errors in bronchial washing and brushing specimens

Laurentia Nodit, Ronald Balassanian, Daniel Sudilovsky, Stephen S. Raab

Research output: Contribution to journalArticle

25 Citations (Scopus)

Abstract

Detailed root cause analysis to determine causes of pulmonary cytology errors has not been used to design specific practice changes. We performed root cause analysis of all false-negative bronchial brushing and washing specimen errors (n = 32) detected by the cytologic-histologic correlation process in 2002. Medical records and all slides were reviewed. Based on the correlation process, 10 errors were interpretive, 16 sampling, and 6 combined interpretive/sampling. Root cause analysis showed that the lesion was not accessible in 8 cases and tumor was readily identified on the slides in only 1 case. In 11 cases, the malignant cells were few and not recognized, and in 13 cases, obscuring artifacts (eg, cellular crushing and air drying) limited interpretation. Sampling issues had a major role in the misdiagnosis in 31 cases (97%), and recommendations for error reduction include immediate interpretation and the use of transmucosal fine-needle aspiration.

Original languageEnglish (US)
Pages (from-to)883-892
Number of pages10
JournalAmerican Journal of Clinical Pathology
Volume124
Issue number6
DOIs
StatePublished - Dec 1 2005
Externally publishedYes

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Root Cause Analysis
Cell Biology
Fine Needle Biopsy
Diagnostic Errors
Artifacts
Medical Records
Air
Lung
Neoplasms

All Science Journal Classification (ASJC) codes

  • Pathology and Forensic Medicine

Cite this

Improving the quality of cytology diagnosis : Root cause analysis for errors in bronchial washing and brushing specimens. / Nodit, Laurentia; Balassanian, Ronald; Sudilovsky, Daniel; Raab, Stephen S.

In: American Journal of Clinical Pathology, Vol. 124, No. 6, 01.12.2005, p. 883-892.

Research output: Contribution to journalArticle

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