Minimizing mistakes through a culture of communication:Open communication and collaboration may be key to preventing errors and learning from them as cytopathology expands its role in diagnostic and treatment decisions. It is the stuff of nightmares in cytopathology: A mislabeled specimen leads to an incorrect diagnosis or procedure on the wrong anatomical site or even the wrong patient. Attention to detail is a necessity in the field, from the pre-analytic phases of specimen labeling and identification through the analytic phase of making the right diagnosis and the postanalytic phase of accurate and complete reporting. As cytopathology becomes increasingly integrated in complicated diagnostic and therapeutic decisions and as the responsibilities of cytotechnologists continue to expand, the potential consequences of errors are likewise growing in magnitude. Minimizing mistakes and the resulting harm to patients, experts say, will require a comprehensive strategy that prioritizes collaboration, mul-tidisciplinary decision-making, and multidirectional communication that transcends customary hierarchical structures to ward off a culture of deflection and blame.
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