Mislabeling Rates of Cases, Specimens, Blocks and Slides; a College of American Pathologists Study of 136 Institutions.
Raouf E Nakhleh, Michael O Idowu, Rhona Souers, Leonas G Bekeris. Mayo Clinic Florida, Jacksonville; VCU Health System, Richmond, VA; Phoenixville Hospital, PA; College of American Pathologists, Northfield, IL
Background: Proper specimen labeling is a major safety initiative by the Joint Commission and the College of American Pathologists. Mishaps in specimen labeling have led to patient injury due to wrong side or wrong patient treatment or due to delay in diagnosis. Our aim is to quantify the rates of mislabeled cases, specimens, blocks and slides and identify the sources of error as well as how they are detected.
Design: This was conducted as a voluntary subscription Q-Probes study. Participants prospectively reviewed surgical pathology cases for an eight week period or until 30 errors related to mislabeled cases, specimens, blocks and slides were identified. Information collected on each labeling error included the work location, what was mislabeled, the number affected, the point of detection, and the outcome. Institutional demographics and practice variables were also collected. The rates of mislabeled cases, specimens, blocks and slides were tested for association with institutional demographics and practice variables.
Results: 136 institutions provided information on a total of 1811 mislabeling occurrences. The overall rate (per 1000) of mislabeling were 1.1 cases, 1.0 specimen, 1.7 blocks and 1.1 slides. In terms of frequency 27.1% were cases, 19.8% specimens, 25.5% blocks and 27.7% slides. 20.9% of errors occurred before accessioning, 12.4 at accessioning, 21.7% at block labeling, 10.2% during grossing and 30.4% at tissue cutting. Errors were typically detected in the 1-2 steps following the error. Lower mislabeled slide rates were associated with continuous individual case accessioning and having formal checks at accessioning. Lower mislabeled specimen rates were associated with routinely including a statement in the gross description that the specimen is labeled with the patient's name and is properly identified. In 96.7% of errors the only outcome was correction of the error, in 3.2% a corrected report was issued, but in 1.3% patient care was affected.
Conclusions: This study demonstrated the mislabeling rate of cases (0.11%), specimens (0.1%), blocks (0.17%) and slides (0.11%). Errors in labeling appear nearly equally throughout the system of accessioning, grossing and tissue cutting. Errors are typically detected in the immediate steps following where the errors occurred reinforcing the need for quality checks throughout the system.
Category: Quality Assurance
Monday, February 28, 2011 1:00 PM
Poster Session II # 202, Monday Afternoon