Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Cytopathology. 2020 Sep;31(5):402-410. doi: 10.1111/cyt.12801. Epub 2020 Feb 21.
Rapid on-site evaluation (ROSE) has been widely used to improve diagnostic adequacy and facilitate specimen triage. Telecytology ROSE has gained popularity recently and shown high concordance with traditional ROSE. However, telecytology involves multiple personnel and technical devices that could introduce additional errors. The aim of this paper is to share errors encountered and lessons learned since employing telecytology for ROSE at our institution.
The laboratory information system was searched for all documented telecytology ROSE errors from 2017 to 2019. These errors were subclassified as technical errors, cytotechnologist-related errors and pathologist-related errors. The following details were recorded for each reported event: type of error, reason for error, ROSE diagnosis, final diagnosis and actions taken to avoid future errors.
Telecytology ROSE errors were documented in 46 (1.3%) sessions. Ten (22%) had technical errors, 13 (28%) were owing to cytotechnologist errors and 23 (50%) were attributed to pathologist interpretation errors. The majority of the technical (90%) and cytotechnologist errors (85%) occurred within the first year of implementation of telecytology. Common ROSE misinterpretation errors included missing microorganisms, misclassifying neuroendocrine tumours as other neoplasms and overcalling malignancy on gastrointestinal endoscopic procedures.
A variety of errors may occur during telecytology ROSE. While some errors are inevitable (eg, information technology downtime), certain telecytology errors can be reduced by increasing staff familiarity with the system, providing timely feedbacks and taking prompt corrective actions. We recommend establishing a mechanism to document and act upon recorded errors as part of a telecytology quality improvement programme.
快速现场评估（ROSE）已被广泛用于提高诊断充分性和促进标本分类。远程细胞学 ROSE 最近越来越受欢迎，并且与传统 ROSE 具有高度一致性。然而，远程细胞学涉及多个人员和技术设备，可能会引入额外的错误。本文的目的是分享自我们机构采用远程细胞学进行 ROSE 以来遇到的错误和吸取的教训。
从 2017 年到 2019 年，通过实验室信息系统搜索所有记录的远程细胞学 ROSE 错误。这些错误被细分为技术错误、细胞技术人员相关错误和病理学家相关错误。对于每个报告的事件，记录了以下详细信息：错误类型、错误原因、ROSE 诊断、最终诊断以及为避免未来错误而采取的措施。
在 46 次（1.3%） ROSE 中记录了远程细胞学 ROSE 错误。其中 10 次（22%）为技术错误，13 次（28%）归因于细胞技术人员错误，23 次（50%）归因于病理学家解释错误。大多数技术（90%）和细胞技术人员错误（85%）发生在远程细胞学实施的第一年。常见的 ROSE 错误包括遗漏微生物、错误地将神经内分泌肿瘤归类为其他肿瘤以及过度诊断胃肠道内镜检查程序中的恶性肿瘤。
在远程细胞学 ROSE 中可能会发生各种错误。虽然有些错误是不可避免的（例如，信息技术停机），但通过增加工作人员对系统的熟悉程度、提供及时的反馈和采取及时的纠正措施，可以减少某些远程细胞学错误。我们建议建立一种机制，记录和处理记录的错误，作为远程细胞学质量改进计划的一部分。
