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Reducing Labeling Errors in Histopathology Specimens: A Quality Improvement Initiative on Endometrial vs.
Background:
Mislabeling of endometrial vs. endocervical curettings was the most frequent specimen error in the Division of Obstetrics & Gynaecology at KK Women's and Children's Hospital, Singapore. These look-alike/sound-alike (LASA) errors can compromise patient safety and workflow efficiency. The authors aimed to reduce specimen labeling errors over a two-year quality improvement (QI) period.
Methods:
Following root cause analysis, a multidisciplinary QI project was initiated in a single tertiary obstetrics & gynecology center using the Plan-Do-Study-Act (PDSA) methodology. Between 2020 and 2022, interventions were (1) a pilot system-level enhancement to the electronic ordering interface; (2) clinician education, training, and monthly feedback; (3) team-based process redesign emphasizing accountability and safety culture; and (4) a subsequent system-level enhancement to the electronic ordering interface during a second PDSA cycle. The primary outcome was the rate of endometrial vs. endocervical mislabeling events per 1,000 orders. The researchers plotted time-series run charts and u-charts and calculated pre- and postintervention incidence rate ratios (IRRs).
Results:
Among 42,968 curettings from January 2020 to May 2025, 46 endometrial/endocervical mislabeling events occurred. Mislabeling rates were 3.79 per 1,000 orders at baseline (9/2,373; January-May 2020), 3.80 between two PDSA cycles (33/8,683; June 2020-April 2021), and 0.13 following the second PDSA cycle (4/31,912; from May 2021), corresponding to a 96.7% reduction vs. baseline (IRR 0.03, 95% confidence interval [CI] 0.01-0.11, p < 0.001). Time-series charts showed a sustained special cause shift since May 2021, with 30 consecutive zero-error months between January 2022 and June 2024.
Conclusion:
A combination of education, feedback, process audits, and interface redesign effectively addressed mislabeling of endometrial/endocervical specimens, a high-impact patient safety concern. This approach may be transferable to other LASA error domains.