title: The effectiveness of inking needle core prostate biopsies for preventing patient specimen identification errors: a technique to address Joint Commission patient safety goals in specialty laboratories.
abstract: BACKGROUND
  The elimination or reduction of medical errors has been a main focus of health care enterprises in the United States since the year 2000. Elimination of errors in patient and specimen identification is a key component of this focus and is the number one goal in the Joint Commission's 2008 National Patient Safety Goals Laboratory Services Program.
  
  
  OBJECTIVE
  To evaluate the effectiveness of using permanent inks to maintain specimen identity in sequentially submitted prostate needle biopsies.
  
  
  METHODS
  For a 12-month period, a grossing technician stained each prostate core with permanent ink developed for inking of pathology specimens. A different color was used for each patient, with all the prostate cores from all vials for a particular patient inked with the same color. Five colors were used sequentially: green, blue, yellow, orange, and black. The ink was diluted with distilled water to a consistency that allowed application of a thin, uniform coating of ink along the edges of the prostate core. The time required to ink patient specimens comprising different numbers of vials and prostate biopsies was timed. The number and type of inked specimen discrepancies were evaluated.
  
  
  RESULTS
  The identified discrepancy rate for prostate biopsy patients was 0.13%. The discrepancy rate in terms of total number of prostate blocks was 0.014%. Diluted inks adhered to biopsy contours throughout tissue processing. The tissue showed no untoward reactions to the inks. Inking did not affect staining (histochemical or immunohistochemical) or pathologic evaluation. On average, inking prostate needle biopsies increases grossing time by 20%.
  
  
  CONCLUSIONS
  Inking of all prostate core biopsies with colored inks, in sequential order, is an aid in maintaining specimen identity. It is a simple and effective method of addressing Joint Commission patient safety goals by maintaining specimen identity during processing of similar types of gross specimens. This technique may be applicable in other specialty laboratories and high-volume laboratories, where many similar tissue specimens are processed.
authors.affiliation: Department of Anatomic Pathology, UroPartners LLC Laboratory, 2225 Enterprise Drive, Westchester, IL 60154, USA. lraff@lab.uropartners.com
authors.forename: Lester J
authors.initials: LJ
authors.lastname: Raff
authors.forename: George
authors.initials: G
authors.lastname: Engel
authors.forename: Kenneth R
authors.initials: KR
authors.lastname: Beck
authors.forename: Andrea S
authors.initials: AS
authors.lastname: O'Brien
authors.forename: Meagan E
authors.initials: ME
authors.lastname: Bauer
mesh_terms: D001707:Biopsy, Needle / Q000379:methods*; D019411:Clinical Laboratory Techniques; D006040:Goals; D006801:Humans; D007281:Ink; D007753:Laboratories / Q000592:standards*; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D009313:National Health Programs; D010355:Patient Identification Systems / Q000379:methods*; D011467:Prostate / Q000473:pathology*; D017751:Safety Management / Q000379:methods; D013048:Specimen Handling / Q000379:methods