Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.

Area of Science:

• Clinical diagnostics
• Laboratory medicine
• Patient safety

Background:

• Laboratory diagnostics are crucial for clinical decision-making.
• The preanalytical phase is prone to manual errors, impacting patient safety.
• Patient misidentification errors carry severe clinical consequences, including misdiagnosis and incorrect treatment.

Purpose of the Study:

• To highlight the prevalence and causes of patient misidentification in laboratory diagnostics.
• To analyze the adverse outcomes associated with these errors.
• To propose guidelines for preventing and detecting misidentification.

Main Methods:

• Review of literature on laboratory specimen misidentification.
• Analysis of error causes and clinical consequences.
• Development of prevention and detection strategies.

Main Results:

• Patient misidentification in general laboratory specimens occurs at approximately 1%.
• Errors can lead to significant patient harm if not detected promptly.
• Direct-positive identification, IT, automation, multiple identifiers, and delta checks are key strategies.

Conclusions:

• Patient misidentification is a significant risk in laboratory diagnostics.
• Implementing proposed guidelines can mitigate risks.
• Specimen rejection and recollection are crucial upon detection of misidentification.