Specimen Labeling Errors: A Q-Probes Analysis of 147 Clinical Laboratories (Report‪)‬

In early surveys, laboratory errors were classified in several ways, including cause, phase of testing, responsible party, and impact on the patient. (1) Data from these studies and other sources have shaped our thinking and caused a shift in the approach to laboratory errors. We have now come to recognize that most errors occur outside of the analytic phase and are often beyond the immediate control of the laboratory. (2,3) Patient identification and specimen handling are error-prone steps that occur primarily outside the laboratory. In a recent survey of error types associated with invasive procedures, 10 of 17 were related to patient identification failure. (4) The College of American Pathologists has surveyed wristband identification errors in a Q-Tracks format and shown that continuous quality monitoring improves patient identification practices. (5,6) Both the College of American Pathologists and the Joint Commission have implemented patient identification as a major patient safety goal for 2008. (7,8) Specimen labeling errors are a recognized preanalytic source of concern for appropriate patient identification management. In several studies, it has been determined that specimen identification errors occur at a rate ranging from 0.1% to 5%. (9-12)