Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.
Laboratory diagnostics, a pivotal part of clinical decision making, is no safer than other areas of healthcare, with most errors occurring in the manually intensive preanalytical process. Patient misidentification errors are potentially associated with the worst clinical outcome due to the potential for misdiagnosis and inappropriate therapy. While it is misleadingly assumed that identification errors occur at a low frequency in clinical laboratories, misidentification of general laboratory specimens is around 1% and can produce serious harm to patients, when not promptly detected. This article focuses on this challenging issue, providing an overview on the prevalence and leading causes of identification errors, analyzing the potential adverse consequences, and providing tentative guidelines for detection and prevention based on direct-positive identification, the use of information technology for data entry, automated systems for patient identification and specimen labeling, two or more identifiers during sample collection and delta check technology to identify significant variance of results from historical values. Once misidentification is detected, rejection and recollection is the most suitable approach to manage the specimen.
Lippi
Giuseppe
G
University of Verona, Verona, Italy.
Blanckaert
Norbert
N
Bonini
Pierangelo
P
Green
Sol
S
Kitchen
Steve
S
Palicka
Vladimir
V
Vassault
Anne J
AJ
Mattiuzzi
Camilla
C
Plebani
Mario
M
D019411:Clinical Laboratory Techniques; D003951:Diagnostic Errors / Q000517:prevention & control / Q000592:standards; D001330:Electronic Data Processing / Q000592:standards*; D006801:Humans; D010338:Pathology, Clinical / Q000592:standards*; D010355:Patient Identification Systems; D012680:Sensitivity and Specificity; D013048:Specimen Handling / Q000592:standards*