No room for error: reducing specimen mislabeling
Safe treatment is dependent on the correct diagnosis being assigned to the correct patient. Therefore, proper patient specimen handling, which includes labeling, is a crucial factor in ensuring accuracy. Patient label identification errors can have serious consequences—mislabeled or misinterpreted specimens can lead to incorrect diagnoses and incorrect treatment. It is critical that blocks and slides can be easily identified in a manner that is clear to everyone handling the material.
Where most errors occur in the histology workflow
- Labeling and releasing slides 35%
- Gross dissecting 28%
- Tissue cutting and slide mounting 23%
- Accessioning 6.5%
- Embedding 4.5%
- Processing 1.5%
- Coloring 1.5%
Lack of automation leads to error
Technology is helping reduce misidentification
Simplifying workflows, implementation of bar code technology and adoption of LIS generated just-in-time labeling of slides prior to staining has been shown to help reduce misidentification errors. In fact, one hospital employed barcoding to reduce their overall misidentification case rate by 62% and their rate of more common histologic slide misidentification defects by 95%.iii
When it comes to patient safety, just one error out of a thousand can do harm. It is in everyone’s best interest to ensure that specimens are labeled correctly. Employing the right technology in your workflow can help reduce and eliminate the root causes of misidentification rates.
i Morelli, P., Ruspini, M., Restelli, U., & Banfi, G. (2013). Analysis of errors in histology by root cause analysis: a pilot study. Journal of Preventive Medicine and Hygiene, 54, 90-96.
ii Heher, MD, MPH, Y. K., Chen, MPH, Y., Pyatibrat, MD, S., Yoon, MD, E., Goldsmith, MD, J. D., & Sands, MD, MPH, K. E. (2016, November). Achieving High Reliability in Histology: An Improvement Series to Reduce Errors. American Journal of Clinical Pathology, 146, 554-560.
iii Zarbo, MD, DMD, R. J., Tuthill, MD, J., D'angelo, MS ASQ CQE SSBB, R., Varney, ASQ CQE SSBB, R., Mahar, B., Neuman, C., & Ormsby, MD, A. (2009). The Henry Ford Production System: Reduction of Surgical Pathology In-Process Misidentfication Defects by Bar Code-Specified Work Process Standardization. American Journal of Clinical Pathology, 131, 468-477.