title: The role of 2D bar code and electronic cross-matching in the reduction of misidentification errors in a pathology laboratory. A safety system assisted by the use of information technology.
abstract: BACKGROUND
  Mismatching of patients and specimens can lead to incorrect histopathological diagnoses. Most misidentification errors in laboratories occur during the manual pre-laboratory and laboratory phases. In the past few years, we have examined this vital and challenging issue in our unit and introduced appropriate procedures. Recently, we have paid special attention to the problem of specimen mix-ups in the gross examination phase and the mismatching of blocks and slides in the cutting phase.
  
  
  OBJECTIVE
  We have focused on the reduction of the potential sources of mismatching of specimen containers, tissue blocks and slides, focusing in particular on the most critical steps which are gross cutting and preparation of microtome sections.
  
  
  METHODS
  A 2D bar code directly printed on the labels of specimen containers, and directly printed onto cassettes and slides, is now being used; in addition, the system performs an electronic cross-check of tissue blocks and slides, which is managed by the laboratory information system.
  
  
  RESULTS
  The present system permits full sample traceability from the moment samples reach the laboratory to the issuing of the final report. Indeed, the LIS records samples, blocks and slides in real time throughout the entire procedure, as well as the operator's name, and the date and time each individual procedure is done. This facilitates later monitoring of the entire workflow.
  
  
  CONCLUSIONS
  The introduction of 2D bar code and electronic cross-checking represents a crucial step in significantly increasing the safe management of cases and improving the quality of the entire work process.
authors.affiliation: U.O. Anatomia Patologica e Citologia, Ospedale Infermi, Rimini, Italy. giovanna.fabbretti@auslrn.net
authors.forename: G
authors.initials: G
authors.lastname: Fabbretti
mesh_terms: D002984:Clinical Laboratory Information Systems / Q000295:instrumentation / Q000592:standards; D001330:Electronic Data Processing / Q000295:instrumentation / Q000379:methods* / Q000592:standards; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D010338:Pathology, Clinical / Q000295:instrumentation / Q000379:methods* / Q000592:standards; D011785:Quality Assurance, Health Care / Q000379:methods* / Q000592:standards; D013048:Specimen Handling / Q000295:instrumentation / Q000379:methods* / Q000592:standards