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 “ And our October 11, 2011 Patient Safety Tip of the Week “ ” describes use of LEAN principles to improve lab safety and efficiency.“ and November 16, 2010 “ ” for discussions on specimen identification, labeling, etc.
Some of our other columns on errors related to laboratory studies:
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
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
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.