Double slide viewing as a cytology quality improvement initiative

American Journal of Clinical Pathology
Stephen S RaabLaila Dahmoush

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.

References

Nov 1, 1993·The American Journal of Surgical Pathology·R E Safrin, C J Bark
Dec 7, 2002·Quality & Safety in Health Care·K H Roberts, C T Tadmor
Dec 19, 2002·Quality & Safety in Health Care·J S CarrollS Hatakenaka
Dec 4, 2003·Quality & Safety in Health Care·P Hudson
Nov 24, 2004·Clinics in Laboratory Medicine·Stephen S Raab
Nov 24, 2004·Clinics in Laboratory Medicine·Dana Marie Grzybicki

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Citations

May 19, 2007·American Journal of Clinical Pathology·Stephen S RaabKim R Geisinger

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