Sample Misidentification Errors in Clinical Laboratories and Prevention Strategies
DOI:
https://doi.org/10.22399/ijcesen.4644Keywords:
sample misidentification, clinical laboratories, errors, prevention strategies, labeling, specimen handlingAbstract
Sample misidentification errors are significant concerns in clinical laboratories, as they can lead to incorrect diagnoses, inappropriate treatments, and adverse patient outcomes. These errors often stem from improper labeling, sample handling, or miscommunication among healthcare staff. For instance, mislabeling specimens can occur during collection, processing, or transportation, resulting in samples being mixed up or attributed to the wrong patient. Such incidents not only compromise the integrity of the laboratory results but also erode patient trust in healthcare systems. The repercussions can be severe, ranging from unnecessary medical interventions to delayed diagnosis and treatment, ultimately affecting patient safety and health outcomes. To mitigate sample misidentification errors, clinical laboratories must implement robust prevention strategies. One effective approach is adopting the use of barcoding systems, which facilitate accurate sample tracking from collection to analysis. Automation and electronic health records can further enhance accuracy by providing real-time access to patient information and sample status, reducing the likelihood of human error. Additionally, staff training and education are critical components of prevention, as they ensure that all personnel are aware of protocols and best practices related to specimen handling and identification. Regular audits and quality control measures can also identify potential weaknesses in the laboratory process, allowing for continuous improvement and enhanced patient safety.
References
1. Lippi G, Guidi GC. Risk management in the preanalytical phase of laboratory testing. Clinical Chemistry and Laboratory Medicine. 2007;45:720–7.
2. WHO guidelines on drawing blood: best practices in phlebotomy. WHO Press; Geneva, Switzerland: 2010. World Health Organization.
3. Plebani M, Astion ML, Barth JH, Chen W, de Oliveira Galoro CA, Escuer MI. et al. Harmonization of quality indicators in laboratory medicine. A preliminary consensus. Clinical Chemistry and Laboratory Medicine. 2014;52:951–8.
4. Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. Journal of General Internal Medicine. 2003;18:61–7.
5. Acheampong F, Anto BP, Koffuor GA. Medication safety strategies in hospitals–a systematic review. International Journal of Risk & Safety in Medicine. 2014;26:117–31.
6. Graber ML. The IOM report on improving diagnosis: new concepts. Diagnosis. 2015;2:201–3.
7. Ajami S, Rajabzadeh A. Radio Frequency Identification (RFID) technology and patient safety. Journal of Research in Medical Sciences. 2013;18:809–13.
8. Nalla PR, Chalavadi KM. Iris classification based on sparse representations using on-line dictionary learning for large-scale de-duplication applications. Springerplus. 2015;4:238.
9. Lippi G, Sonntag O, Plebani M. Appropriate labelling of blood collection tubes: a step ahead towards patient’s safety. Clinical Chemistry and Laboratory Medicine. 2011;49:1921–3.
10. Procedures for collection of diagnostic blood specimens by venipuncture; approved guideline – 6th ed. CLSI document GP41-A6. Wayne, PA: Clinical and Laboratory Standards Institute; 2007. Clinical and Laboratory Standards Institute.
11. Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clinics in Laboratory Medicine. 2004;24:979–96.
12. Danaher LA, Howells J, Holmes P, Scally P. Is it possible to eliminate patient identification errors in medical imaging? Journal of the American College of Radiology. 2011;8:568–74.
13. Lippi G, Simundic AM, Mattiuzzi C. Overview on patient safety in healthcare and laboratory diagnostics. Biochemia Medica. 2010;20:131–43.
14. Harris County Hospital District. Harris County Hospital District Puts Patient Safety in the Palm of Your Hand.
15. Wagar EA, Stankovic AK, Raab S, Nakhleh RE, Walsh MK. Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories. Archives of Pathology & Laboratory Medicine. 2008;132:1617–22.
16. Lippi G, Mattiuzzi C, Banfi G, Buttarello M, Caputo M, Daves M. et al. Proposal of a checklist for venous blood collection. Biochimica Clinica. 2013;37:312–7.
17. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V. et al. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clinical Chemistry and Laboratory Medicine. 2009;47:143–53.
18. College of American Pathologists. Valenstein PN, Raab SS, Walsh MK. Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. Archives of Pathology & Laboratory Medicine. 2006;130:1106–13.
19. Kohn KT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
20. Lippi G, Plebani M. Identification errors in the blood transfusion laboratory: a still relevant issue for patient safety. Transfusion and Apheresis Science. 2011;44:231–3.
21. Gomatam S, Carter R, Ariet M, Mitchell G. An empirical comparison of record linkage procedures. Statistics in Medicine. 2002;21:1485–96.
22. Xie J, Zhang L, You J, Zhang D, Qu X. A study of hand back skin texture patterns for personal identification and gender classification. Sensors. 2012;12:8691–709.
23. Plebani M. Laboratory-associated and diagnostic errors: a neglected link. Diagnosis. 2014;1:89–94.
24. van Dongen-Lases EC, Cornes MP, Grankvist K, Ibarz M, Kristensen GB, Lippi G. et al. Patient identification and tube labelling – a call for harmonisation. Clinical Chemistry and Laboratory Medicine. 2016;54:1141–5.
25. Lippi G, Caputo M, Banfi G, Buttarello M, Ceriotti F, Daves M. et al. Recommendations for collection of venous blood. Biochimica Clinica. 2008;32:569–77.
26. Lippi G, Plebani M, Graber ML. Building a bridge to safe diagnosis in health care. The role of the clinical laboratory. Clinical Chemistry and Laboratory Medicine. 2016;54:1–3.
27. Patient Identification. Patient Safety Solutions. Volume 1, Solution 2. WHO Press, World Health Organization; Geneva, Switzerland: 2007. World Health Organization, Joint Commission and Joint Commission International.
28. Carraro P, Plebani M. Errors in a stat laboratory: types and frequencies 10 years later. Clinical Chemistry. 2007;53:1338–42.
29. UK National Patient Safety Agency. Safer patient identification.
30. Henneman PL, Fisher DL, Henneman EA, Pham TA, Campbell MM, Nathanson BH. Patient identification errors are common in a simulated setting. Annals of Emergency Medicine. 2010;55:503–9.
31. Joint Commission. Sentinel Event Data Summary.
32. Aykal G, Keşapli M, Aydin O, Esen H, Yeğin A, Güngör F. et al. Pre-Test and Post-Test Applications to Shape the Education of Phlebotomists in A Quality Management Program: An Experience in A Training Hospital. Journal of Medical Biochemistry. 2016;35:347–53.
33. Piva E, Tosato F, Plebani M. Pre-analytical phase: The automated ProTube device supports quality assurance in the phlebotomy process. Clinica Chimica Acta. 2015;451:287–91.
34. Joint Commission. 2016 National Patient Safety Goals.
35. Lippi G, Banfi G, Buttarello M, Ceriotti F, Daves M, Dolci A. et al. Recommendations for detection and management of unsuitable samples in clinical laboratories. Clinical Chemistry and Laboratory Medicine. 2007;45:728–36.
36. Nakhleh RE, Zarbo RJ. Surgical pathology specimen identification and accessioning: A College of American Pathologists Q-Probes Study of 1 004 115 cases from 417 institutions. Archives of Pathology & Laboratory Medicine. 1996;120:227–33.
37. Hawker CD, McCarthy W, Cleveland D, Messinger BL. Invention and validation of an automated camera system that uses optical character recognition to identify patient name mislabeled samples. Clinical Chemistry. 2014;60:463–70.
38. Ning HC, Lin CN, Chiu DT, Chang YT, Wen CN, Peng SY. et al. Reduction in Hospital-Wide Clinical Laboratory Specimen Identification Errors following Process Interventions: A 10-Year Retrospective Observational Study. PLoS One. 2016;11:e0160821.
39. Lima-Oliveira G, Lippi G, Salvagno GL, Picheth G, Guidi GC. Laboratory Diagnostics and Quality of Blood Collection. Journal of Medical Biochemistry. 2015;34:288–94.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 International Journal of Computational and Experimental Science and Engineering
This work is licensed under a Creative Commons Attribution 4.0 International License.
