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Erroneous Patient Tissue Contaminants in 1574 Surgical Pathology Slides: Impact on Diagnostic Error and a Novel
Simon Lamothe1, Masa Peric1, Jonathan N Glickman1
1From the Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Lamothe, Peric, Glickman).
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 fingerprinting.
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.
Insights
Tissue contaminants on histology slides are common and pose a diagnostic risk. This study proposes a standardized classification and algorithm for managing these "floaters" to improve patient safety.
Area of Science:
- Histopathology
- Diagnostic Pathology
- Patient Safety
Background:
- Tissue contaminants on histology slides are a significant source of diagnostic error.
- Lack of standardized criteria for defining and managing contaminants leads to variability in pathology reporting.
- Underreporting of tissue contamination events poses a patient safety risk.
Purpose of the Study:
- To determine the frequency and types of tissue contaminants on microscopic slides.
- To develop standardized criteria and an algorithm for the identification, workup, and reporting of tissue contaminants.
- To enhance patient safety by providing a framework for managing slide contamination.
Main Methods:
- Retrospective analysis of 1574 histologic glass slides.
- Prospective study of 50 slide contamination events.
- Development of a classification taxonomy and management guidelines.
Main Results:
- Tissue contaminants were identified on 3.3% of slides in the retrospective arm.
- Key evaluation parameters include size, location, folding, ink, and tissue of origin.
- Ancillary testing strategies like FISH and DNA fingerprinting were successfully employed.
Conclusions:
- Tissue contamination is underreported and constitutes a patient safety concern.
- A reproducible classification taxonomy and standardized algorithm can help pathologists manage and reduce risks associated with contaminants.
- Implementing these tools can improve the understanding and reporting of tissue contamination events.
