title: Specimen Identification Errors in Breast Biopsies: Age Matters. Report of Two Near-Miss Events and Review of the Literature.
abstract: The consequences of patient identification errors due to specimen mislabeling can be deleterious. We describe two near-miss events involving mislabeled breast specimens from two patients who sought treatment at our institution. In both cases, microscopic review of the slides identified inconsistencies between the histologic findings and patient age, unveiling specimen identification errors. By correlating the clinical information with the microscopic findings, we identified mistakes that had occurred at the time of specimen accessioning at the original laboratories. In both cases, thanks to a timely reassignment of the specimens, the patients suffered no harm. These cases highlight the importance of routine clinical and pathologic correlation as a critical component of quality assurance and patient safety. A review of possible specimen identification errors in the anatomic pathology setting is presented.
authors.affiliation: Department of Pathology, Wexler Medical Center at The Ohio State University, Columbus, Ohio.
authors.forename: Gary
authors.initials: G
authors.lastname: Tozbikian
authors.affiliation: Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York City, New York.
authors.forename: Mary L
authors.initials: ML
authors.lastname: Gemignani
authors.affiliation: Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York City, New York.
authors.forename: Edi
authors.initials: E
authors.lastname: Brogi
mesh_terms: D000008:Abdominal Neoplasms / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000473:pathology; D011125:Adenomatous Polyposis Coli / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000473:pathology; D000293:Adolescent; D000368:Aged; D001706:Biopsy; D001943:Breast Neoplasms / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000473:pathology; D044584:Carcinoma, Ductal / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000473:pathology; D003937:Diagnosis, Differential; D005260:Female; D018222:Desmoid Tumors / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000473:pathology; D006801:Humans; D008327:Mammography; D019300:Medical Errors; D008875:Middle Aged; D017698:Postmenopause
keywords: Monckeberg medial calcific sclerosis; biopsy; breast; laboratory error; lactating adenoma; needle core; specimen misidentification