Specimen Labeling Errors in an Anatomic Pathology Laboratory: An Eighteen Month Experience
LJ Layfield, GM Anderson. University of Utah School of Medicine, Salt Lake City, UT; ARUP Laboratories, Salt Lake City, UT
Background: The recognition and elimination of medical errors is an important issue for both clinicians and pathologists. Errors occurring in the Anatomic Pathology laboratory can involve a variety of processes including specimen labeling, specimen processing and staining as well as diagnostic interpretation. Little has been published on the frequency of specimen labeling errors. Such mislabeling can occur at pre-analytic, analytic, and post-analytic points.
Design: We reviewed our experience with mislabeled specimens for a 12 month period. During that period, 29,479 cases were accessioned and associated with 109,354 blocks and 248,013 slides. Percentage error was calculated on a block and slide basis. Errors were characterized as mislabeled specimen containers/request forms (clinic), mislabeled blocks (gross room), mislabeled slides (histology laboratory) and mislabeled immunohistochemistry slides (immunohistochemistry laboratory). Labeling errors were characterized as major (wrong patient) or minor (same patient but different specimen site).
Results: Fifty-nine major labeling errors were detected (0.05% of blocks and 0.024% of total slides) and 31 minor labeling errors were found representing 0.03% of total blocks and 0.012 % if total slides. The majority (63%) of mislabeled specimens occurred within the gross room due to incorrect labeling of the cassettes submitted to the histology laboratory. These errors were detected in the histology laboratory or by the sign-out pathologist.
Conclusions: While infrequent, labeling errors occur and do involve specimen misidentification as to patient and specimen source. Two-thirds (59 of 90) of labeling errors resulted in assigning the slides to the incorrect patient. The majority of errors in our series occurred within the gross room where cassettes were assigned an incorrect number. This frequently led to the slide being mislabeled and associated with the incorrect patient. Increasing attention to the gross room phase of specimen labeling appears warranted to reduce the frequency of specimen mislabeling. Newer technologies such as bar coding and chip techniques may aid in reducing the frequency of labeling errors.
Category: Quality Assurance
Monday, March 22, 2010 1:00 PM
Poster Session II # 203, Monday Afternoon