Negligence in Interpretation of Pap Smears

What Can Go Wrong Sometimes Does
A True Story (continued)

All laboratories will benefit from a re-examination of their policies to assure they:

1. Guarantee communication of vital historical and clinical data between the clinician and the service laboratory.

2. Issue no report on a Pap smear specimen if necessary historical data has not confidently been obtained.

3. Issue no report on a Pap smear specimen without a concurrent review of the patient record within the service laboratory and a comparison of slides, if indicated.

4. Utilize the accumulation of statistical data concerning the interpretation of Pap smears on a monthly basis to identify and act upon areas of concern.

Reduction in morbidity and mortality due to cervical cancer has been a miracle of this century to which cytopathology has made a decisive contribution. New technologies have been suggested to reduce the false-negative risk further such as thin layer preparations and selected hybrid capture testing for HPV DNA. Nevertheless, significant reductions in true-false negative screening can be wrenched from the existing technology. Concerns about liability exposure should not lead, as it has, to the promulgation of literature suggesting that the interpretation of cytology specimens is an artistic endeavor without a scientific basis. The scientific basis of cytologic interpretation, evolved laboriously over decades, creates the framework within which all instruction in this field is carried out. Academic nihilism suggests it is not possible in a particular given instance to correctly interpret a slide by resort to accepted principles of interpretation. It is human nature that drivers of cars will sometimes go through red lights and stop signs, cross center lines, tailgate, etc. But the inevitability of such carelessness does not mean that on each and every occasion where one goes through a stop sign that they should not be held responsible for the error where that error harms another.

Every time that a screener of a Pap smear is distracted and looks without seeing, we should examine the causes of the distraction and find ways to avoid such vacant observations rather than asserting that to look without seeing is the standard by which practice should be measured. If multiple individual cells are present with high nuclear cytoplasmic ratios, hyperchromasia, indistinct cell boundaries, and nuclear chromatin clumps, surely a tissue examination is warranted. In many academic centers ASCUS is a basis for colposcopy. For two or more ascus reports colposcopy is required.**[footnote required-American College of Obstetricians and Gynecologists: Cervical Cytology: Evaluation and Management of Abnormalities. Technical Bulletin no. 183, August 1993]** The distinction between whether a lesion is a low grade lesion which may disappear or a high grade lesion which will likely not disappear, should not be a distinction used to justify a classification system or practice which prevents a more accurate diagnostic procedure from being secured.

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