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February 2006
PAP/NGC Programs Review
CAP Cytopathology Committee*
I and the co-authors of the Cancer article thank the members
of the CAP Cytopathology Committee for their thought-provoking article.
As the members point out, the study of medical error is a challenge, and
researchers disagree even on the definition of medical error. We accept
the Institute of Medicine definition of error as "the failure of a planned
action to be completed as intended or the use of a wrong plan to achieve
an aim." Applying this to diagnostic testing is not straightforward, and
we consider that a diagnostic testing error is one in which the interpretation
rendered is not descriptive of the actual pathologic process in the patient.
We choose to look at the entire testing pathway and recognize that the
pathology processes compose only a portion. Our root-cause analytic studies
indicate that it often is difficult to identify the specific processes
that fail when a diagnostic error occurs. The example provided by the
members of the CAP Cytopathology Committee highlights this issue. In this
scenario, a patient undergoes a fine needle aspiration of a sclerotic
lung nodule that shows only scant benign fibrous tissue and the subsequent
excisional biopsy shows malignancy. The committee members wrote, "[M]any
reasonable individuals would not consider this an error," and "There was
no interpretive error by the cytopathologist...." Perhaps. However, using
the Institute of Medicine definition, an error occurred because there
was a failure in the test to reach the diagnosis. Errors are defined from
the patient perspective and not on the root-cause analytic adjudication
process that separates errors into interpretation or sampling.
In some cases, the root cause of the error may be sampling factors such
as radiologist experience or patient-related-factors that are beyond the
control of the physicians involved in the care management. We believe
that these issues need to be better studied and that pathologists have
a key role in determining why these errors occur and in decreasing the
frequency of error.
* Members of the CAP Cytopathology Committee are David C. Wilbur, MD,
chair; Joel S. Bentz, MD; Christine Noga Booth, MD; Karen M. Clary, MD;
Amy C. Clayton, MD; Camilla J. Cobb, MD; Terence J. Colgan, MD; Teresa M.
Darragh, MD; Barbara S. Ducatman, MD; Michael R. Henry, MD; Nicholas J.
Hruby, MD; Jonathan H. Hughes, MD, PhD; Gladwyn Leiman, MBBCh; Ann T. Moriarty,
MD; Marianne Unger Prey, MD; Mary R. Schwartz, MD; William D. Tench, MD;
Theresa M. Voytek, MD; Patricia G. Wasserman, MD; Nancy A. Young, MD; Maureen
F. Zakowski, MD; and Sarah E. Rollins, MD. |
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