Francis Dawn L, Prabhakar Shalini, Sanderson Schuyler O
Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Am J Gastroenterol. 2009 Apr;104(4):972-5. doi: 10.1038/ajg.2008.170. Epub 2009 Mar 3.
Our institution has had problems with mislabeling of tissue specimens in our gastrointestinal and colorectal surgery endoscopy units. Most labeling errors have been due to either the wrong patient label or no label being affixed to a specimen bottle. As a result, an initiative was created to reduce the number of specimen-labeling errors. This initiative involved the application of radiofrequency identification (RFID) technology to specimen bottles, moving to a paperless pathology requisition system and confirmation of the correct site and correct patient by both the endoscopy nursing staff and the endoscopist for each specimen bottle.
We reviewed the number of specimen-labeling errors from our endoscopy unit for the first 3 months of 2007, before the implementation of the initiative, and for the first 3 months of 2008, 6 months after the initiation of RFID specimen labeling with paperless requisition and two-provider confirmation of correct site, correct patient specimen labeling. The RFID system we used was an off-the-shelf 3M (St. Paul, MN) Library Sciences RFID system modified and installed for our purposes. Specimen-labeling errors were categorized as Class 1 (only typographical with no potential clinical consequences), Class 2 (minor error, unlikely to have clinical consequences) or Class 3 (significant error that has the potential to detrimentally impact patient care). The Fischer's exact test was used to compare the rate of specimen-bottle labeling errors before and after the initiation of this new system.
In the first 3 months of 2007, our endoscopy unit sent 8,231 specimen bottles to our pathology laboratory for evaluation; 8,539 bottles were sent in the first 3 months of 2008. There were 646 (7.85%) Class 1 errors in the first quarter of 2007 and 35 (0.41%) in the first quarter of 2008 (P<0.001). There were 112 (1.36%) Class 2 errors in the first quarter of 2007 and 10 (0.12%) in the first quarter of 2008 (P<0.001). Finally, in the first quarter of 2007 there were seven (0.09%) Class 3 errors and in the first quarter of 2008, there were two (0.02%) Class 3 errors. However, with the new system in place, both Class 3 errors in the first quarter of 2008 were recognized and corrected before the processing of the specimens in the pathology laboratory (P=0.001).
These data confirm that the initiation of a new specimen-labeling system that uses RFID technology, a paperless requisition process, and confirmation of the correct site and correct patient by two health-care providers significantly decreased specimen-labeling errors at every level in a high-volume endoscopy center.
我们机构在胃肠和结直肠手术内镜科室的组织标本标签标注方面存在问题。大多数标签错误要么是患者标签错误，要么是标本瓶未粘贴标签。因此，我们发起了一项减少标本标签错误数量的倡议。该倡议包括将射频识别（RFID）技术应用于标本瓶，采用无纸化病理申请系统，并由内镜护理人员和内镜医师对每个标本瓶的正确部位和正确患者进行确认。
我们回顾了2007年实施该倡议前内镜科室前3个月以及2008年（即启动RFID标本标签标注、采用无纸化申请并由两名医护人员确认正确部位和正确患者标本标签标注6个月后）前3个月的标本标签错误数量。我们使用的RFID系统是现成的3M（明尼苏达州圣保罗）图书馆科学RFID系统，根据我们的需求进行了修改和安装。标本标签错误分为1类（仅为排版错误，无潜在临床后果）、2类（轻微错误，不太可能有临床后果）或3类（严重错误，有可能对患者护理产生不利影响）。采用费舍尔精确检验来比较新系统启动前后标本瓶标签错误率。
2007年前3个月，我们的内镜科室将8231个标本瓶送至病理实验室进行评估；2008年前3个月送了8539个标本瓶。2007年第一季度有646例（7.85%）1类错误，2008年第一季度有35例（0.41%）（P<0.001）。2007年第一季度有112例（1.36%）2类错误，2008年第一季度有10例（0.12%）（P<0.001）。最后，2007年第一季度有7例（0.09%）3类错误，2008年第一季度有2例（0.02%）3类错误。然而，在新系统实施后，2008年第一季度的两例3类错误在病理实验室处理标本前就被发现并纠正了（P=0.001）。
这些数据证实，采用RFID技术、无纸化申请流程以及由两名医护人员确认正确部位和正确患者的新标本标签标注系统，在一个大容量内镜中心显著降低了各个层面的标本标签错误。
