Mixups… Last week we talked about breastmilk mixups. And we’ve
previously talked about baby
mixups. And recently we’ve had a flurry of hits
on our previous columns regarding specimen mixups (Patient Safety Tips of the Week for October
9, 2007 “Errors
in the Laboratory”, November 16, 2010 “Lost
Lab Specimens”, March
6, 2012 ““Lab”
Error”, and January 22, 2013 “You
Don’t Know What You Don’t Know” and our April 2012 What’s New in the
Patient Safety World column “Specimen
Labeling Errors”).
Standardized measurements
of surgical specimen identification defects have been lacking. But recently
multidisciplinary members of a panel from hospitals participating in the
Michigan Health and Hospital Association (MHHA) Keystone Center for Patient
Safety and Quality developed a set of practical measures to quantify specimen
identification defects in the preanalytic phase (Bixenstine
2013). They developed 12 measures
(6 container and 6 requisition identification defects), then piloted data
collection at 69 hospitals participating in the MHHA Keystone project over a
3-month period. Overall, there were identification defects in 2.9% of cases.
There were defects in 1.2% of containers and in 2.3% of requisitions.
An excellent review
on preventing specimen mixups was published earlier
this year by Dr. Wolfgang Weyers (Weyers
2014). Though written from the perspective of a dermatopathologist,
it really applies to all surgical specimen mixups
(and really to a whole host of laboratory specimen mixups,
too). He nicely describes the literature on the issue of specimen mixups and discusses ways to minimize the risks using
several themes:
Weyers notes that in the lifecycle of a surgical specimen it
may go through 20+ people and several workplaces. It can be even more
complicated when specimens are going to another facility or organization.
Standardization
Weyers emphasizes that good
organization of all the steps involved is the best way to prevent specimen mixups. That begins with standardization. Examples he
provides are always taking sample bottles with formalin from the same place,
always depositing specimens in the same way, arranging slides or cassettes in
the same manner, and many others. Color-coding of specimens is another
standardized method often used, though Weyers notes
even it is subject to error.
Automation
Using computers and technology is another means to prevent
mistakes. Because manual labeling of specimens is error-prone, automatic
labeling of blocks or specimens in a printer may help prevent mistakes. Barcoding significantly helps alleviate
transcription errors.
Readability and Understandability
While illegible handwriting is a frequent source of error
leading to specimen mixups, even computer use can
lead to errors. For example, he notes that short codes inadvertently keyed into
the computer transposed can result in serious errors. He therefore notes that
sometimes using a longer code that conveys more obvious meaning may be
preferable.
Redundancy
Using at least 2 unrelated data elements (as required anyway
by Joint Commission) is important in avoiding mixups.
That is particularly important when names are the same or similar.
Orderliness/Tidiness/Cleanliness
Weyers would be appalled to see
our desk when we are doing columns! He really emphasizes how workplaces in the
lab must be tidy and the need to keep
only one procedure in sight. That applies equally in the operating room
where files and specimens of the current patient should be kept separate from
all other files and specimens.
He also cautions against labeling bottles and request forms
prior to biopsies because the course of action is sometimes changed during the
procedure (eg. change in the sequence of biopsies or
addition of another biopsy).
Checking the specimen bottles and request forms for
completeness is extremely important. Even the simple act of ensuring that any
adhesive labels adhere firmly to the specimen bottle is critical.
Order also needs to be maintained during unpacking of specimens
and all other subsequent work.
In discussing cleanliness, he notes how specimens or pieces
thereof may slip and fall or flip away. For that reason (and others) the floor
should be kept very clean. For the same reason the floor should be kept a light
uniform color without decorations that might make it difficult to spot a
dropped specimen. (See also our November 16, 2010 Patient Safety Tip of the
Week “Lost
Lab Specimens” for more information on lost specimens.) He also
notes how “ribbons” of tissue specimens may be transferred from an instrument
to a slide or float in a bath and be inadvertently picked up on another slide
(see also our January 22, 2013 Patient
Safety Tip of the Week “You
Don’t Know What You Don’t Know”).
Mutual Control
Weyers describes two forms of
mutual control: simultaneous and downstream. By simultaneous mutual control he
means having two individuals involved in the same action calling attention
immediately to any error by the other. He notes these should be done in the
most vulnerable steps of the biopsy pathway. He notes that accessioning of
specimens in the laboratory, including unpacking and sorting and numbering
bottles and request forms, is one particularly vulnerable time and therefore
should be done by two individuals simultaneously. (Note, however, some of our
prior comments on double checks as in our October 16, 2012 Patient Safety Tip of the Week “What
is the Evidence on Double Checks?”).
An example of
downstream mutual control might be identifying and marking any discrepancies so
that downstream work recognizes those errors.
Communication
Communication is two-way. Adequate completion of the request
forms is so important that Weyers recommends the
physician himself or herself complete these. Delegation to someone who may not
understand the importance of such entries often results in errors or incomplete
requests. Similarly, communication back to the requesting physician is
important, particularly when there has been incomplete information on the
request form.
Weyers also has lots of other
practical recommendations in his review:
It’s Everybody’s job!
Weyers notes that every one of the
20+ people who may be involved with the specimen start-to-end processes has a
role in detection of potential or actual errors. He notes that even the
secretaries transcribing reports can identify such errors. For example, they
might note inconsistencies such as description of a cancer in a report that
concludes “no cancer found”.
The paperclip did it!
We almost used this for the title of today’s column! Weyers
even notes the role the lowly but highly utile paperclip can play in causing
specimen mixups. He notes that paperclips that attach
some additional information to a request form may catch another request form, resulting
in more than one form being put aside after dictation, and the next report may
be issued erroneously for the wrong patient. Of course, in the old paper
medical record era we often saw reports in the wrong patient chart because they
adhered to another report.
Weyers also issues a warning we’ve
made on multiple occasions: “Don’t ever
allow files on 2 patients open at same time”. That significantly increases
the possibility that data meant for one patient may be interpreted or included
for another patient. He also reminds us to beware
of “cut and paste” noting that sometimes there is on the computer clipboard
information from a previous patient that inadvertently gets pasted into a new
patient record.
He also discusses
how interruptions and distractions may contribute to errors and how both high and
low workloads may facilitate errors.
He has a good
discussion about the importance of documentation of errors. That
obviously should include not only errors that resulted in patient harm or near
misses but also minor errors that may uncover latent factors that may
contribute to future errors. Along that vein, the system described by Bixenstine et al. looks all the more important.
He also describes
DNA molecular identity testing for cases in which specimen mixups
are suspected (we’ve also discussed such testing in several of the columns
referenced below).
Read the Weyers article. It has many more good ideas than we can
summarize in our column. And read our many prior columns addressing the serious
issue of specimen mixups.
Some of our other
columns on errors related to laboratory studies:
References:
Bixenstine PJ, Zarbo
RJ, Holzmueller CG, et al. Developing and Pilot
Testing Practical Measures of Preanalytic Surgical Specimen
Identification Defects. American
Journal of Medical Quality 2013; 28(4): 308-314 first published on
January 15, 2013
http://ajm.sagepub.com/content/28/4/308.abstract
Weyers W. Confusion - specimen
mix-up in dermatopathology and measures to prevent
and detect it. Dermatol Pract
Concept 2014; 4: 27-42
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3919837/pdf/dp0401a04.pdf
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