Department of Pathology, University of Utah School of Medicine, Huntsman Cancer Hospital, Salt Lake City, UT 84112, USA.
Am J Clin Pathol. 2010 Sep;134(3):466-70. doi: 10.1309/AJCPHLQHJ0S3DFJK.
Elimination of medical errors is important for pathologists. Errors occurring in surgical pathology involve specimen defects, specimen labeling, processing, diagnosis, and reporting defects. Errors occur during prelaboratory, laboratory, and postlaboratory phases. We reviewed our experience with mislabeled specimens in the laboratory for an 18-month period. The percentage of error was calculated on a per case, block, and slide basis. Errors were characterized by site and as incorrect patient or site. The study involved 75 labeling errors (0.25% of cases) that were detected. Of the 75 errors, 55 (73%) involved patient name, and 18 (24%) involved site. The majority of mislabelings (52 [69%]) occurred in the gross room. Although infrequent, labeling errors involved misidentification of patient or specimen source. Of the errors, 73% (55/75) of errors resulted in slides assigned to an incorrect patient. Most errors occurred in the gross room. Newer technologies such as bar coding and radio frequency chip methods may reduce the frequency of specimen labeling errors.
消除医疗差错对于病理学家来说很重要。手术病理中出现的差错涉及标本缺陷、标本标记、处理、诊断和报告缺陷。差错发生在实验前、实验中和实验后阶段。我们回顾了 18 个月来实验室中标记错误的标本的经验。按每例、每块和每张切片计算误差百分比。差错的特征是部位和患者或部位错误。这项研究涉及到 75 个（0.25%）被检测到的标记错误。在 75 个错误中，55 个（73%）涉及患者姓名，18 个（24%）涉及部位。大多数标记错误（52 个[69%]）发生在大体标本室。尽管不常见，但标记错误涉及患者或标本来源的错误识别。在这些错误中，73%（55/75）的错误导致切片被分配给错误的患者。大多数错误发生在大体标本室。新的技术，如条形码和射频芯片方法，可能会减少标本标记错误的频率。
