Measures to reduce diagnostic error and improve clinical decision making in thyroid fine needle aspiration cytology: a proposed framework

Background: Thyroid FNA cytology and histopathology is a highly subjective area of medical diagnosis, subject to different interpretations and prone to error. Based on the authors' personal experience 12 recommendations to improve clinical decision-making, ensure quality, and reduce diagnostic error in thyroid fine-needle aspiration cytology (FNAC) and histopathology are presented.

Summary: 12 recommendations are proposed. (i) Use a standardized reporting terminology for thyroid fine needle aspiration cytology (FNAC) (ii) Understand and explain to service users the limitations of cytology and the standardized thyroid FNAC reporting terminology utilized, (iii) The cytopathologist should review all relevant clinical and ultrasound findings if feasible, (iv) Include the risk of malignancy in all FNAC reports if feasible, (v) Collect data to calculate the local institutional risk of malignancy for FNAC if feasible (vi) Accept that non-diagnostic FNAC will include small numbers of carcinomas, (vii) Utilize rapid on-site evaluation and/or educational sessions for aspirators if the non-diagnostic aspiration rate is high, (viii) Know the diagnostic pitfalls of both cytopathology and histopathology, (ix) Use special immunohistochemical and molecular techniques that are evidence-based, (x) Make use of second opinions, either in-house or inter-institutional, (xi) Multidisciplinary discussion of cases prior to surgery or therapy is invaluable, and finally (xii) Manage patient and clinician expectations of thyroid cytopathology and histopathology.

Conclusion: These 12 recommendations assist in quality improvement initiatives and reduce diagnostic errors in thyroid cytopathology and histopathology. Thyroid multidisciplinary case discussion remains the principal over-arching method for error reduction and providing high quality clinical decision making.