Erroneous Patient Tissue Contaminants in 1574 Surgical Pathology Slides: Impact on Diagnostic Error and a Novel Framework for Floater Management.
Context.--Tissue contaminants on histology slides represent a serious risk of diagnostic error. Despite their pervasive presence, published peer-reviewed criteria defining contaminants are lacking. The absence of a standardized diagnostic workup algorithm for contaminants contributes to variation in...
| Publicado en: | Archives of Pathology & Laboratory Medicine Vol. 148; no. 12; pp. 1413 - 1422 |
|---|---|
| Autores principales: | , , , |
| Formato: | algorithm pictorial research tables/charts Journal Article |
| Publicado: |
College of American Pathologists
Dec2024
|
| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=181184763&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 181184763 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 00039985 1FS jtl: Archives of Pathology & Laboratory Medicine issn: 00039985 maglogo: N pubinfo: dt: Dec2024 vid: 148 iid: 12 pid: 2550 pub: College of American Pathologists place: Northfield, Illinois artinfo: ui: 181184763 181184763 181184763 10.5858/arpa.2022-0265-OA 181184763 ppf: 1413 ppct: 9 formats: fmt: @attributes: type: P tig: atl: Erroneous Patient Tissue Contaminants in 1574 Surgical Pathology Slides: Impact on Diagnostic Error and a Novel Framework for Floater Management. aug: au: Lamothe, Simon Peric, Masa Glickman, Jonathan N. Heher, Yael K. affil: Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts sug: subj: Pathology, Clinical Equipment Contamination Classification Diagnostic Errors Patient Safety Histology Microscopy Equipment Contamination Prevention and Control Human Massachusetts Massachusetts Academic Medical Centers Prospective Studies Retrospective Design Record Review Pathologists Chromosomes Analysis Descriptive Statistics In Situ Hybridization, Fluorescence DNA Fingerprinting Algorithms Specimen Handling Histocytological Preparation Techniques ab: Context.--Tissue contaminants on histology slides represent a serious risk of diagnostic error. Despite their pervasive presence, published peer-reviewed criteria defining contaminants are lacking. The absence of a standardized diagnostic workup algorithm for contaminants contributes to variation in management, including investigation and reporting by pathologists. Objective.--To study the frequency and type of tissue contaminants on microscopic slides using standardized criteria. Using these data, we propose a taxonomy and algorithm for pathologists on "floater" management, including identification, workup, and reporting, with an eye on patient safety. Design.--A retrospective study arm of 1574 histologic glass slides as well as a prospective study arm of 50 slide contamination events was performed. Using these data we propose a structured classification taxonomy and guidelines for the workup and resolution of tissue contamination events. Results.--In the retrospective arm of the study, we identified reasonably sized benign tissue contaminants on 52 of 1574 slides (3.3%). We found size to be an important parameter for evaluation, among other visual features including location on the slide, folding, ink, and tissue of origin. The prospective arm of the study suggested that overall, pathologists tend to use similar features when determining management of potentially actionable contaminants. We also report successfully used case-based ancillary testing strategies, including fluorescence in situ hybridization analysis of chromosomes and DNA finger-printing. Conclusions.--Tissue contamination events are underreported and represent a patient safety risk. Use of a reproducible classification taxonomy and a standardized algorithm for contaminant workup, management, and reporting may aid pathologists in understanding and reducing risk. pubtype: Academic Journal doctype: algorithm pictorial research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
|---|