Specimen labeling errors in surgical pathology: an 18-month experience.

Area of Science:

• Medical error reduction in pathology
• Surgical pathology quality control

Background:

• Medical errors in pathology can occur at various stages, including pre-laboratory, laboratory, and post-laboratory phases.
• Specimen labeling errors are a significant concern within surgical pathology, impacting patient safety and diagnostic accuracy.

Purpose of the Study:

• To analyze the incidence and characteristics of mislabeled specimens within a pathology laboratory.
• To identify the primary sources and types of specimen labeling errors to inform error reduction strategies.

Main Methods:

• A retrospective review of laboratory records over an 18-month period.
• Analysis of detected mislabeled specimens, calculating error rates per case, block, and slide.
• Categorization of errors by site and type (incorrect patient or incorrect site).

Main Results:

• A total of 75 labeling errors were identified, representing 0.25% of all cases.
• The majority of errors (73%) involved incorrect patient identification, and 24% involved incorrect site identification.
• Most mislabeling incidents (69%) occurred in the gross room, with 73% of errors leading to slides being assigned to the wrong patient.

Conclusions:

• Specimen labeling errors, though infrequent, pose a risk in surgical pathology, particularly concerning patient misidentification.
• The gross room is a critical area for implementing interventions to reduce labeling errors.
• Adoption of advanced technologies like barcoding and radio frequency identification may decrease the occurrence of these errors.