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Errors in Thyroid Gland Fine-Needle Aspiration

Stephen S. Raab MD, Colleen M. Vrbin, Dana Marie Grzybicki MD, PhD, Daniel Sudilovsky MD, Ronald Balassanian MD, Richard J. Zarbo MD, DMD, Frederick A. Meier MD
DOI: http://dx.doi.org/10.1309/7RQE37K6439T4PB4 873-882 First published online: 1 June 2006

Abstract

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 preanalytic (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 preanalytic and analytic portions of the diagnostic pathway.

Key Words:
  • Cytology
  • Thyroid gland
  • Patient safety
  • Quality improvement