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Error detection via patient engagement: Wrong‐side designation in cytology reports of a computed tomography–guided lung biopsy with rapid on‐site evaluation

• A 54-year old woman underwent a computed tomography–guided core biopsy of a left upper lobe lung nodule. • A cytotechnologist and a cytopathologist were on site in the radiology department. The radiology department had provided a printed requisition sheet indicating that the left lung was to be biopsied. The cytotechnologist and the cytopathologist made an assessment of adequacy, recorded the assessment, and correctly transcribed the laterality of the biopsy onto a cytology worksheet. • After completion of the procedure, the sample, requisition sheet, and on-site assessment worksheet were transported to the cytology laboratory. • The specimen was accessioned in the cytology laboratory. The laterality was incorrectly entered into the provisional and ultimately final cytology report as “Lung, right (CTguided needle core biopsy and touch imprint cytology).” • The screening cytotechnologist, the cytopathologist who rendered the final diagnosis, and the treating clinician who received the final report did not detect this error. Separate PD-L1 immunohistochemistry and molecular pathology reports were initiated by support staff and subsequently issued by a different pathologist, with the incorrect laterality designated. • Before surgery, the patient contacted her treating clinician through her electronic patient portal (EPP) because she had detected the laterality error upon her review of the cytology reports in the portal (Fig. 1). • The clinician notified the cytology service of the error, all reports were corrected, and the patient was informed that the corrections had been made. • The patient subsequently underwent a successful left lobectomy.