title: Double slide viewing as a cytology quality improvement initiative.
abstract: Few studies have measured the effect of pre-sign out double viewing of cytology cases as a means to decrease error. Three Agency for Healthcare Research and Quality-funded project sites performed pre-sign out double viewing of 431 pulmonary cytology cases. Two-step or more differences in diagnosis were arbitrated as interpretive errors, and the effect of double viewing was measured by comparing the frequency of cytologic-histologic correlation-detected errors in the previous 2 years with the double-viewing period. The number of interpretive errors detected by double viewing for the 3 institutions was 2.7%, 0% and 1.9%, respectively. Double viewing did not lower the frequency of cytologic-histologic correlation false-negative errors. We conclude that double viewing detects errors in up to 1 of every 37 cases and that biases in the double-viewing process limit error detection.
authors.affiliation: Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15232, and Henry Ford Health System, Detroit, MI, USA.
authors.forename: Stephen S
authors.initials: SS
authors.lastname: Raab
authors.forename: Chad H
authors.initials: CH
authors.lastname: Stone
authors.forename: Chris S
authors.initials: CS
authors.lastname: Jensen
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Zarbo
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Meier
authors.forename: Dana M
authors.initials: DM
authors.lastname: Grzybicki
authors.forename: Colleen M
authors.initials: CM
authors.lastname: Vrbin
authors.forename: N Paul
authors.initials: NP
authors.lastname: Ohori
authors.forename: Laila
authors.initials: L
authors.lastname: Dahmoush
mesh_terms: D018288:Carcinoma, Small Cell / Q000175:diagnosis*; D003581:Cytodiagnosis / Q000379:methods* / Q000592:standards*; D003951:Diagnostic Errors / Q000517:prevention & control*; D005188:False Negative Reactions; D006801:Humans; D008175:Lung Neoplasms / Q000175:diagnosis*; D010338:Pathology, Clinical / Q000379:methods / Q000592:standards; D015203:Reproducibility of Results