title: Patient misidentification in Papanicolaou tests: a systems-based approach to reducing errors.
abstract: BACKGROUND
  Patient safety is of prime concern in every laboratory. Double labeling of glass slides is performed in many cytology laboratories where handwritten patient information on the frosted portion of the glass is overlaid with paper labels (sometimes containing bar codes). The cytotechnologists match this information by turning slides over. We use SurePath liquid-based cytology for Papanicolaou tests in our laboratory and noticed patient misidentification because of slide labeling errors, a problem that has not been addressed in the literature.
  
  
  OBJECTIVE
  To reduce slide labeling errors without increasing costs, using a systems-based approach.
  
  
  METHODS
  All errors from mislabeled slides during November 2006 were documented, and an informal root-cause analysis was performed. Slides were labeled on opposite ends and monitored for errors.
  
  
  RESULTS
  Labeling on different ends of the glass slide reduced our error rate from 0.59% to 0%, made visual matching easy, and did not alter costs.
  
  
  CONCLUSIONS
  The practice of overlaying handwritten information with printed labels for liquid-based Papanicolaou tests should be strongly discouraged and replaced with placing patient information in separate portions of the glass slide so that crucial patient identification is not hidden and visual matching is easy.
authors: Department of Pathology, Dartmouth Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756, USA.
authors: Erin
authors: E
authors: Meyer
authors: R Shawn
authors: RS
authors: Underwood
authors: Vijayalakshmi
authors: V
authors: Padmanabhan
mesh_terms: D005260:Female; D006801:Humans; D007755:Laboratories, Hospital / Q000592:standards*; D019300:Medical Errors / Q000517:prevention & control*; D065006:Papanicolaou Test; D010338:Pathology, Clinical / Q000592:standards*; D010355:Patient Identification Systems; D013048:Specimen Handling / Q000592:standards*; D014626:Vaginal Smears