Seminars in Diagnostic Pathology
Volume 24, Issue 2 , Pages 77-88 , May 2007

Error reduction and risk management in cytopathology

  • William J. Frable, MD

      Affiliations

    • Corresponding Author InformationAddress reprint requests and correspondence: William J. Frable, MD, VCU/MCV Department of Pathology, P.O. Box 980662, Richmond, VA 23298-0662.

References 

  1. In:  Kohn LT,  Corrigan JM,  Donaldson MS editor. To Err is Human (Building a Safer Health System). Washington DC: National Academy Press; 2000;
  2. Keepmews D, Mitchell PH. Health systems’ accountability for patient safety. Online J Issues Nurs. 2003;8:2
  3. Clinton HR, Obama BS. A bill to amend the Public Health Service Act to promote a culture of safety within the health care system through establishment of a National Medical Error Disclosure and Compensation Program. 2005;Press Release, Barack Obama, September 28
  4. Koss LG, Melamed MR. In: Koss’ Diagnostic Cytopathology and Its Histopathologic Bases. (ed 5). Philadelphia, PA: Lippincott Williams & Wilkins; 2006;p. 8–9
  5. Priest P, Sadler L, Peters J, et al. Pathways to diagnosis of cervical cancer: screening history, delay in follow up, and smear reading. BJOG. 2007;114:398–407
  6. Troxel DB, Sabella JD. Problem areas in pathology practice (Uncovered by a review of malpractice claims). Am J Surg Pathol. 1994;18:821–831
  7. Troxel DB. Error in surgical pathology. Am J Surg Pathol. 2004;28:1092–1095
  8. Troxel DB. Medicolegal aspects of error in pathology. Arch Pathol Lab Med. 2006;130:617–619
  9. Troxel DB. Diagnostic pitfalls in surgical pathology: uncovered by a review of malpractice claims (Part II. Breast fine needle aspirations). Int J Surg Pathol. 2000;8:229–231
  10. Troxel DB. Diagnostic pitfalls in surgical pathology: discovered by a review of malpractice claims (Part III. Breast biopsies). Int J Surg Pathol. 2000;8:335–337
  11. Troxel DB. Diagnostic pitfalls in surgical pathology: discovered by a review of malpractice claims (Part VII. Random errors). Int J Surg Pathol. 2001;9:305–308
  12. Troxel DB. Pitfalls in the diagnosis of malignant melanoma; findings of a risk management panel study. Am J Surg Pathol. 2003;27:1278–1283
  13. Troxel DB. Diagnostic pitfalls in surgical pathology: discovery by a review of malpractice claims. Int J Surg Pathol. 2001;9:133–136
  14. Voelker R. Milwaukee deaths reignite critical issues in cervical cancer screening. J Am Med Assoc. 1995;273:1559–1560
  15. The Doctors Company, unpublished data
  16. Shoop SA. Cervical cancer screening risk management perspectives. Great Falls, VA: Corporate Laser; 2006;PIAA Claims Workshop, October 19, 2006.
  17. Wied GL. Quality control mechanism for cytology programs. Acta Cytol. 1965;9:407–412
  18. Inhorn SL. Governmental legislation affecting cytology laboratories. Acta Cytol. 1976;20:197–202
  19. New pap tests suggested for air force dependents. US Medicine 1. 1978;August
  20. Bogdanich W. The Pap test misses much cervical cancer through lab’s efforts. The Wall Street Journal 1. 1987;Nov 2
  21. Bogdanich W. Physician’s carelessness with Pap tests is cited in procedure’s high failure rate. The Wall Street Journal 17. 1987;Dec 29
  22. Frable WJ. Litigation in gynecologic cytology. Pathol Case Rev. 2005;10:106–114
  23. Austin RM. Results of blinded rescreening of Papanicolaou smears versus biased retrospective review. Arch Pathol Lab Med. 1997;121:311–314
  24. Renshaw AA, Young ML, Holladay EB. Blinded review of Papanicolaou smears in the context of litigation. Cancer. 2004;102:136–141
  25. Jamal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin. 2006;56:106–130
  26. Frable WJ, Austin RM, Greening SE, et al. International Academy of Cytology Task Force summary Medicolegal affairs (Diagnostic cytology towards the 21st century: an international expert conference and tutorial). Acta Cytol. 1998;42:76–119discussion 120-132
  27. Rosenthal DL, Marzella RJ: Cytoteleconference. American Society of Cytopathology, Philadelphia, 1996-97
  28. Austin RM. In search of a “reasonable person standard” for gynecologic cytologists. Diagn Cytopathol. 1994;11:216–218
  29. Fitzgibbons PL, Austin RM Surgical Pathology Committee and Cytopathology Committee of the College of American Pathologists. Expert review of histologic slides and Papanicolaou tests in the context of litigation or potential litigation. Arch Pathol Lab Med. 2000;124:1717–1719
  30. Web site, American Society of Cytopathology. Available at. http://www.cytopathology.org/.
  31. Raab SS, Andrew-Jaja C, Condel JL, et al. Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods. Am J Obstet Gynecol. 2006;194:57–64
  32. Vrbin CM, Grzybicki DM, Zaleski MS, et al. Variability in cytologic-histologic correlation practices and implications for patient safety. Arch Pathol Lab Med. 2005;129:893–898
  33. Solomon D, Nayar R. The Bethesda System for Reporting Cervical Cytology. 2nd Edit.. New York, NY: Springer-Verlag; 2004;
  34. Davey E, Barratt A, Irwig L, et al. Effect of study design and quality on unsatisfactory rates, cytology classifications, and accuracy in liquid-based versus conventional cervical cytology: a systematic review. Lancet. 2006;367:122–132
  35. Willis BH, Barton P, Pearmain P, et al. Cervical screening programmes: can automatioin help? (Evidence from systematic reviews, an economic analysis and a simulation modeling exercise applied to the UK). Health Technol Assess. 2005;9:1–207
  36. Wilbur DC, Parker EM, Foti JA. Location-guided screening of liquid-based cervical cytology specimens: a potential improvement in accuracy and productivity is demonstrated in a preclinical feasibility trial. Am J Clin Pathol. 2002;118:399–407
  37. Wilbur DC, Stoler MH. Testing for human papillomavirus: basic pathobiology of infection, methodologies, and implications for clinical use. Yale J Biol Med. 1991;64:113–125
  38. Stoler MH. Testing for human papillomavirus: data driven implications for cervical neoplasia management. Clin Lab Med. 2003;23:569–583
  39. Stoler MH. HPV testing in cervical cytology practice: it’s all about choice. Acta Cytol. 2005;49:117–119
  40. HMSO. Report of the working party on internal quality control for cervical cytopathology laboratories. 1995;Ediburgh, The Scotish Office
  41. Dudding N, Hewer EM, Lancucki L, et al. Rapid screening: a comparative study. Cytopathology. 2001;12:235–248
  42. Yobs AR, Plott AE, Hicklin MD, et al. Retrospective evaluation of gynecologic cytodiagnosis (II. Intralaboratory reproducibility as shown in rescreening large consecutive samples of reported cases). Acta Cytol. 1987;31:900–910
  43. Davey DD. Papanicolaou smear 5-year retrospective review: what is required by the Clinical Laboratory Improvement Amendments of 1988?. Arch Pathol Lab Med. 1997;121:296–298
  44. Davey DD. Amended reports: when, if ever?. Diagn Cytopathol. 1997;17:399–400
  45. Stastny JF, Geisinger KR, Michael CW, et al. Another quality assurance issue–uamended reports: what do we really know about them?. Diagn Cytopathol. 1998;18:67–70
  46. Epstein JI. Pathologists and the judicial process: how to avoid it. Am J Surg Pathol. 2001;25:527–537

PII: S0740-2570(07)00048-2

doi: 10.1053/j.semdp.2007.03.006

Seminars in Diagnostic Pathology
Volume 24, Issue 2 , Pages 77-88 , May 2007

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