What’s New in the Patient Safety World
April 2012
Specimen Labeling Errors
A recent article on
the OutpatientSurgey.net website highlighted a $1 million malpractice award in
a case of switched pathology specimens (Paige
2012). A patient underwent a robotic prostatectomy and no cancer was found.
It was later discovered that his original biopsy specimen had been switched
with that of another patient. Where and how the swtich occurred could not be
resolved and both the laboratory and the center where the original biopsy had
been done were held liable in the case.
In our March 6, 2012
Patient Safety Tip of the Week ““Lab”
Error” we noted that the vast majority of “lab”errors really occur in the
pre-analytical and post-analytical phases of laboratory evaluation.
A recent report on
laboratory errors collected from 30 healthcare organizations (Snydman 2012) notes
that the top 2 errors were specimen not labeled (18.7%) and specimen mislabeled
(16.3%) and concludes many “lab” errors occur before the specimen ever reaches
the lab and could be prevented by better labeling.
A paper from the
Mayo Clinic (Francis
2009) discusses changes made after their gastrointestinal and colorectal
surgery endoscopy units had experienced mislabeling or no labeling of
specimens. They initiated a new specimen-labeling system that uses RFID
technology, a paperless requisition process, and confirmation of the correct
site and correct patient by 2 healthcare providers. They were able to document
a substantial decrease in errors as a result of the new processes.
But labeling errors may occur with the lab itself. Another paper identified errors in specimen labeling within a surgical pathology laboratory (Layfield 2010). They found labeling errors occurred at a rate of 0.25% of cases and could involve either patient name or site of the specimen. The majority of the mislabelings occurred in the gross room. One theme they noted was that more errors occurred with small specimens that were similar in appearance and were batch processed. They also noted that batch processing had been previously identified in the literature as a root cause of labeling errors in the laboratory.
See our Patient Safety Tips of the Week for October 9, 2007
“Errors
in the Laboratory“ and November 16, 2010 “Lost
Lab Specimens” for discussions on specimen identification,
labeling, etc. And our October
11, 2011 Patient Safety Tip of the Week “LEAN
in the Lab” describes use of LEAN principles to improve lab safety
and efficiency.
Some of our other columns on errors related to laboratory studies:
- October 9, 2007 “Errors in the Laboratory“
- November 16, 2010 “Lost Lab Specimens”
- October 11, 2011 “LEAN in the Lab”
- March 6, 2012 ““Lab” Error”
References:
Paige L. Switched Pathology Specimen Results in Errant Prostate Surgery, $1 Million Settlement. Both urology clinic and pathology lab denied liability, so they shared payment of damages. Outpatientsurgery.net Published: March 6, 2012
Snydman LK, Harubin B, Kumar S, et al. Voluntary Electronic Reporting of Laboratory Errors: An Analysis of 37 532 Laboratory Event Reports From 30 Health Care Organizations. American Journal of Medical Quality March/April 2012 27: 147-153, first published on September 14, 2011
http://ajm.sagepub.com/content/27/2/147.abstract
Francis DL, Prabhakar S, Sanderson SO. A Quality Initiative to Decrease Pathology Specimen–Labeling Errors Using Radiofrequency Identification in a High-Volume Endoscopy Center. Am J Gastroenterol 2009; 104: 972–975
http://www.nature.com/ajg/journal/v104/n4/abs/ajg2008170a.html
Layfield LJ. Anderson GM. Specimen labeling errors in surgical pathology: an 18-month experience. American Journal of Clinical Pathology 2010. 134(3): 466-70, 2010 Sep.
http://ajcp.ascpjournals.org/content/134/3/466.full.pdf+html
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