Department of Pathology, Mayo Clinic Florida, Jacksonville, 32224, USA.
Arch Pathol Lab Med. 2011 Aug;135(8):969-74. doi: 10.5858/2010-0726-CPR.
Accurate specimen labeling is a major patient-safety initiative by the Joint Commission and the College of American Pathologists. Inadequate specimen labels have led to patient injury from wrong patient diagnosis, wrong side treatment, and delay in diagnosis.
To quantify the rates of mislabeled cases, specimens, blocks, and slides and to identify the sources of error and the ways in which errors are detected.
In this voluntary-subscription Q-Probes study, participants prospectively reviewed surgical pathology cases for 8 weeks or until 30 errors (mislabeled cases, specimens, blocks, and slides) were identified. Information collected on each labeling error included the work location where the defect occurred, what was mislabeled, the number of items affected, the point of detection, and the consequences of the mislabeling error, along with institutional demographics and practice. The rates of mislabeled cases, specimens, blocks, and slides were tested for association with institutional demographics and practice variables.
Of the 136 institutions providing information on a total of 1811 mislabeling occurrences, the overall mislabeling rates per 1000 were 1.1 cases, 1.0 specimen, 1.7 blocks, and 1.1 slides. Of all mislabeling events, 27.1% were cases, 19.8% specimens, 25.5% blocks, and 27.7% slides. The work locations at which the errors occurred were 20.9% before accessioning, 12.4% at accessioning, 21.7% at block labeling, 10.2% during gross pathology, and 30.4% at tissue cutting. Errors were typically detected in the first or second steps immediately following the error. Lower mislabeled slide rates were associated with continuous individual case accessioning and use of formal checks at accessioning. Routinely including a statement in the gross description that the specimen is labeled with the patient's name and is properly identified was also associated with lower rates of specimen mislabeling. The errors were corrected before reports were issued 96.7% of the time; for 3.2% of errors, a corrected report was issued. In 1.3% of error occurrences, participants gauged that patient care was affected.
This study quantified mislabeling rates across 136 institutions of cases (0.11%), specimens (0.1%), blocks (0.17%), and slides (0.11%). Errors in labeling appear nearly equally throughout the system of accessioning, gross pathology processing, and tissue cutting. Errors are typically detected in the immediate steps after the errors occurred, reinforcing the need for quality checks throughout the system.
准确的标本标签是联合委员会和美国病理学家学院的一项主要患者安全倡议。不充分的标本标签导致了错误的患者诊断、错误的治疗侧和诊断延误等患者伤害。
量化错误标签的病例、标本、块和切片的发生率，并确定错误的来源以及错误的检测方式。
在这项自愿订阅的 Q-Probes 研究中，参与者前瞻性地审查了 8 周的外科病理学病例，或者直到发现 30 个错误（错误标签的病例、标本、块和切片）。收集的每个标签错误信息包括缺陷发生的工作地点、错误的标签内容、受影响的物品数量、检测点以及标签错误的后果，以及机构的人口统计学和实践情况。检验了病例、标本、块和切片的错误标签率与机构人口统计学和实践变量的相关性。
在提供了总共 1811 个错误标签事件的信息的 136 个机构中，每 1000 个的错误标签发生率为 1.1 个病例、1.0 个标本、1.7 个块和 1.1 个切片。所有错误标签事件中，27.1%为病例，19.8%为标本，25.5%为块，27.7%为切片。错误发生的工作地点分别为 20.9%在接收前、12.4%在接收时、21.7%在块标签时、10.2%在大体病理学时和 30.4%在组织切割时。错误通常在错误发生后的第一或第二步立即被发现。较低的错误标签切片率与连续的单个病例接收和在接收时使用正式检查相关。在大体描述中常规包含标本用患者姓名标记且正确识别的声明也与较低的标本错误标签率相关。报告发出前，错误 96.7%的时间得到纠正；对于 3.2%的错误，发出了纠正报告。在 1.3%的错误事件中，参与者评估认为患者护理受到影响。
这项研究量化了 136 个机构的病例（0.11%）、标本（0.1%）、块（0.17%）和切片（0.11%）的错误标签率。标签错误在整个接收、大体病理学处理和组织切割系统中几乎均匀分布。错误通常在错误发生后的立即步骤中被发现，这加强了在整个系统中进行质量检查的必要性。
