Patient misidentification in Papanicolaou tests: a systems-based approach to reducing errors

Area of Science:

• Medical laboratory science
• Cytopathology
• Patient safety systems

Background:

• Double labeling of glass slides is common in cytology labs, involving handwritten patient data overlaid with printed labels.
• This method, used with SurePath liquid-based cytology for Papanicolaou tests, can lead to patient misidentification due to labeling errors.
• Such slide labeling errors have not been adequately addressed in existing literature.

Purpose of the Study:

• To implement a systems-based approach to reduce slide labeling errors without incurring additional costs.
• To enhance patient identification accuracy in cytology laboratories.

Main Methods:

• Documented all mislabeled slide errors during a specific period (November 2006).
• Conducted an informal root-cause analysis of identified labeling errors.
• Modified the slide labeling procedure by placing handwritten and printed labels on opposite ends of the glass slide.

Main Results:

• The implemented labeling change reduced the error rate from 0.59% to 0%.
• The new method simplified visual matching of patient information on slides.
• No increase in laboratory costs was associated with the revised labeling procedure.

Conclusions:

• Overlaying handwritten patient information with printed labels for liquid-based Papanicolaou tests should be discontinued.
• Placing patient information on separate, distinct portions of the glass slide enhances visibility and simplifies identification.
• This practice improves crucial patient identification and visual matching, thereby enhancing patient safety.