title: A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.
abstract: OBJECTIVE
  Our institution has had problems with mislabeling of tissue specimens in our gastrointestinal and colorectal surgery endoscopy units. Most labeling errors have been due to either the wrong patient label or no label being affixed to a specimen bottle. As a result, an initiative was created to reduce the number of specimen-labeling errors. This initiative involved the application of radiofrequency identification (RFID) technology to specimen bottles, moving to a paperless pathology requisition system and confirmation of the correct site and correct patient by both the endoscopy nursing staff and the endoscopist for each specimen bottle.
  
  
  METHODS
  We reviewed the number of specimen-labeling errors from our endoscopy unit for the first 3 months of 2007, before the implementation of the initiative, and for the first 3 months of 2008, 6 months after the initiation of RFID specimen labeling with paperless requisition and two-provider confirmation of correct site, correct patient specimen labeling. The RFID system we used was an off-the-shelf 3M (St. Paul, MN) Library Sciences RFID system modified and installed for our purposes. Specimen-labeling errors were categorized as Class 1 (only typographical with no potential clinical consequences), Class 2 (minor error, unlikely to have clinical consequences) or Class 3 (significant error that has the potential to detrimentally impact patient care). The Fischer's exact test was used to compare the rate of specimen-bottle labeling errors before and after the initiation of this new system.
  
  
  RESULTS
  In the first 3 months of 2007, our endoscopy unit sent 8,231 specimen bottles to our pathology laboratory for evaluation; 8,539 bottles were sent in the first 3 months of 2008. There were 646 (7.85%) Class 1 errors in the first quarter of 2007 and 35 (0.41%) in the first quarter of 2008 (P<0.001). There were 112 (1.36%) Class 2 errors in the first quarter of 2007 and 10 (0.12%) in the first quarter of 2008 (P<0.001). Finally, in the first quarter of 2007 there were seven (0.09%) Class 3 errors and in the first quarter of 2008, there were two (0.02%) Class 3 errors. However, with the new system in place, both Class 3 errors in the first quarter of 2008 were recognized and corrected before the processing of the specimens in the pathology laboratory (P=0.001).
  
  
  CONCLUSIONS
  These data confirm that the initiation of a new specimen-labeling system that uses RFID technology, a paperless requisition process, and confirmation of the correct site and correct patient by two health-care providers significantly decreased specimen-labeling errors at every level in a high-volume endoscopy center.
authors.affiliation: Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota 55905, USA. francis.dawn@mayo.edu
authors.forename: Dawn L
authors.initials: DL
authors.lastname: Francis
authors.forename: Shalini
authors.initials: S
authors.lastname: Prabhakar
authors.forename: Schuyler O
authors.initials: SO
authors.lastname: Sanderson
mesh_terms: D004724:Endoscopy / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control* / Q000639:trends; D010338:Pathology, Clinical / Q000379:methods*; D010355:Patient Identification Systems / Q000592:standards*; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D013048:Specimen Handling / Q000379:methods / Q000592:standards*