Identification errors in pathology and laboratory medicine.
Identification errors involve misidentification of a patient or a specimen. Either has the potential to cause patients harm. Identification errors can occur during any part of the test cycle; however, most occur in the preanalytic phase. Patient identification errors in transfusion medicine occur in 0.05% of specimens; for general laboratory specimens the rate is much higher, around 1%. Anatomic pathology, which involves multiple specimen transfers and hand-offs, may have the highest identification error rate. Certain unavoidable cognitive failures lead to identification errors. Technology, ranging from bar-coded specimen labels to radio frequency identification tags, can be incorporated into protective systems that have the potential to detect and correct human error and reduce the frequency with which patients and specimens are misidentified.
Valenstein
Paul N
PN
Pathology Division, Michigan Multispecialty Physicians, 5301 East Huron River Drive, Ann Arbor, MI 48104-3058, USA. paul@valenstein.org
Sirota
Ronald L
RL
D006801:Humans; D007753:Laboratories / Q000592:standards; D019300:Medical Errors / Q000517:prevention & control*; D010338:Pathology, Clinical / Q000592:standards*; D010340:Pathology, Surgical / Q000592:standards*; D010355:Patient Identification Systems; D011785:Quality Assurance, Health Care; D013048:Specimen Handling / Q000592:standards*