From Causatum to Erratum, all in a name

This study highlights how a trivial mistake in collecting timed blood samples of parathyroid hormone (PTH) during parathyroidectomy (PTX) can potentially become a serious error affecting surgical closure.

For the measurement of serum PTH, the intact PTH (iPTH) test was used to obtain baseline, preoperative, intraoperative, and postoperative samples of PTH, to guide the surgical team regarding adequacy of PTX.

Due to the lack of proper guidelines, all types of samples for PTH are labeled as iPTH by the Laboratory Information Services (LIS) software. Due to a human error in marking the PTH vacutainers generated for different time point samples by LIS, samples were swapped. The values in the lab revealed a spurious rise in PTH post-PTX. The laboratory physician carefully observed the tubes and identified the reason for this mistake. The timely action therefore led to surgical closure, otherwise it could have led to unwarranted extended PTX.

In cases where timed samples are mandatory, having a common code for all requisitions can invariably lead to pre-analytical error, therefore proper discriminative measures need to be introduced to avoid these mistakes.