Double Slide Viewing as a Cytology Quality Improvement Initiative
Stephen Spencer Raab, Chad H. Stone, Chris S. Jensen, Richard J. Zarbo, Frederick A. Meier, Dana M. Grzybick, Colleen M. Vrbin, N. Paul Ohori, Laila Dahmoush · American Journal of Clinical Pathology · 2006
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.