title: Improving the quality of cytology diagnosis: root cause analysis for errors in bronchial washing and brushing specimens.
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.
authors.affiliation: Department of Pathology, University of Pittsburgh Medical Center, PA 15232, USA.
authors.forename: Laurentia
authors.initials: L
authors.lastname: Nodit
authors.forename: Ronald
authors.initials: R
authors.lastname: Balassanian
authors.forename: Daniel
authors.initials: D
authors.lastname: Sudilovsky
authors.forename: Stephen S
authors.initials: SS
authors.lastname: Raab
mesh_terms: D001992:Bronchoalveolar Lavage Fluid / Q000166:cytology; D001999:Bronchoscopy; D003951:Diagnostic Errors; D005188:False Negative Reactions; D006801:Humans; D008175:Lung Neoplasms / Q000175:diagnosis*; D010338:Pathology, Clinical / Q000592:standards*; D011787:Quality of Health Care