Related Experiment Video

Updated: May 3, 2026

Enhanced Sample Multiplexing of Tissues Using Combined Precursor Isotopic Labeling and Isobaric Tagging cPILOT
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Published on: May 1, 2017

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How many mislabelled samples go unidentified? Results of a pilot study to determine the occult mislabelled sample

Caitlin Raymond1, Liesel Dell'Osso1, David Guerra1

  • 1Department of Pathology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA.

Journal of Clinical Pathology
|May 20, 2024
PubMed
Abstract

Insights

Many blood sample mislabelling incidents go undetected. This study found a higher rate of unidentified sample mislabelling than previously identified, highlighting critical patient safety issues in clinical laboratories.

Area of Science:

  • Clinical Pathology
  • Laboratory Medicine
  • Patient Safety

Background:

  • Specimen mislabelling is a critical patient safety error that is challenging to detect.
  • Current methods for estimating sample mislabelling may not identify all instances of mislabelled specimens.

Purpose of the Study:

  • To quantify the rate of discrepancies in patient specimen labels.
  • To estimate the prevalence of unidentified (occult) sample mislabelling.

Main Methods:

  • Blood typing was performed on multiple complete blood count specimens sharing the same patient label to identify discrepancies.
  • The rate of identified sample mislabelling was calculated for the study period.

Main Results:

  • A discrepancy rate of 3.17 per 1000 specimens was observed.
  • This discrepancy rate suggests a significant number of unidentified mislabelled samples.
  • The rate of identified sample mislabelling was 1.15 per 1000 specimens.

Conclusions:

  • Identified mislabelled specimens likely represent only a portion of all mislabelled samples.
  • The findings suggest that laboratory error in specimen identification is more widespread than previously recognized.
  • These results have implications for laboratory quality control and patient safety protocols across institutions.
Keywords:
quality assurance, health carequality controlsafety

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