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Specimen labeling errors in surgical pathology: an 18-month experience
Lester J Layfield1, Gina M Anderson
1Department of Pathology, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT 84112, USA.
Abstract:
Elimination of medical errors is important for pathologists. Errors occurring in surgical pathology involve specimen defects, specimen labeling, processing, diagnosis, and reporting defects. Errors occur during prelaboratory, laboratory, and postlaboratory phases. We reviewed our experience with mislabeled specimens in the laboratory for an 18-month period. The percentage of error was calculated on a per case, block, and slide basis. Errors were characterized by site and as incorrect patient or site. The study involved 75 labeling errors (0.25% of cases) that were detected. Of the 75 errors, 55 (73%) involved patient name, and 18 (24%) involved site. The majority of mislabelings (52 [69%]) occurred in the gross room. Although infrequent, labeling errors involved misidentification of patient or specimen source. Of the errors, 73% (55/75) of errors resulted in slides assigned to an incorrect patient. Most errors occurred in the gross room. Newer technologies such as bar coding and radio frequency chip methods may reduce the frequency of specimen labeling errors.
Insights
Pathology specimen labeling errors are critical to prevent. A review found 75 labeling errors, with most involving patient names and occurring in the gross room, highlighting areas for improved patient safety.
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.
