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Identification of Rare Bacterial Pathogens by 16S rRNA Gene Sequencing and MALDI-TOF MS
Published on: July 11, 2016
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[Specimen misidentification in pathology laboratory: trends and measures]
Hiroshi Minato1, Mana Fukushima, Takayuki Nojima
1Department of Pathology and Laboratory Medicine, Kanazawa Medical University, Kahoku-gun, Ishikawa-pref. 920-0293, Japan. hminato@kanazawa-med.ac.jp
Rinsho Byori. the Japanese Journal of Clinical Pathology
|November 14, 2013
Summary
Pathology specimen misidentification occurred in 0.078% of cases. While new technologies and safety measures reduced errors, continuous quality improvement and error reporting remain crucial for patient safety in laboratories.
Area of Science:
- Medical Laboratory Science
- Pathology Quality Assurance
Context:
- Specimen misidentification in pathology poses significant risks.
- Data on the frequency of such errors in Japanese pathology laboratories are limited.
Purpose:
- To review near-miss and incident reports of specimen misidentification over seven years.
- To analyze trends, identify problem areas, and discuss preventative measures.
Summary:
- A 7-year review of 113,447 pathology cases identified 88 instances (0.078%) of specimen misidentification.
- Errors occurred across various stages, with embedding (30%) and accessioning (19%) being most frequent. Most errors involved gross specimens.
- Despite implementing new technologies and safety protocols, misidentification events decreased but were not entirely eliminated.
Impact:
- The study highlights the persistent challenge of specimen misidentification in pathology.
- Implementing barcode reading, digital imaging, and enhanced safety protocols has shown a reduction in errors.
- Continuous quality improvement systems and transparent error reporting are vital for minimizing patient risk.
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