Raab Stephen S, Vrbin Colleen M, Grzybicki Dana Marie, Sudilovsky Daniel, Balassanian Ronald, Zarbo Richard J, Meier Frederick A
Department of Pathology, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15232, USA.
Am J Clin Pathol. 2006 Jun;125(6):873-82. doi: 10.1309/7RQE-37K6-439T-4PB4.
Scant published data exist on redesigning pathology practice based on error data. In this first step of an Agency for Healthcare Research and Quality patient safety project, we measured the performance metrics of thyroid gland fine-needle aspiration, performed root cause analysis to determine the causes of error, and proposed error-reduction initiatives to address specific errors. Eleven cytologists signed out 1,543 thyroid gland aspirates in 2 years, and surgical pathology follow-up was obtained in 364 patients. Of the 364 patients, 91 (25.0%) had a false-negative diagnosis and 36 (9.9%) a false-positive diagnosis. Root cause analysis showed that major sources of error were pre-analytic (poor specimen quality) and analytic (interpretation of unsatisfactory specimens as nonneoplastic and lack of diagnostic category standardization). We currently are evaluating the effectiveness of error reduction initiatives that target pre-analytic and analytic portions of the diagnostic pathway.
关于基于错误数据重新设计病理学实践的已发表数据很少。在医疗保健研究与质量局患者安全项目的这第一步中，我们测量了甲状腺细针穿刺的性能指标，进行根本原因分析以确定错误原因，并提出减少错误的举措以解决特定错误。11位细胞学家在2年内签出了1543份甲状腺吸出物，并对364名患者进行了手术病理随访。在这364名患者中，91例（25.0%）诊断为假阴性，36例（9.9%）诊断为假阳性。根本原因分析表明，主要错误来源是分析前（标本质量差）和分析阶段（将不满意的标本解释为非肿瘤性以及缺乏诊断类别标准化）。我们目前正在评估针对诊断途径中分析前和分析部分的减少错误举措的有效性。
