Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

Archives of Pathology & Laboratory Medicine
Edward J Dunn, Paul J Moga

Abstract

Mislabeled laboratory specimens are a common source of harm to patients, such as repeat phlebotomy; repeat diagnostic procedure, including tissue biopsy; delay in a necessary surgical procedure; and the execution of an unnecessary surgical procedure. Mislabeling has been estimated to occur at a rate of 0.1% of all laboratory and anatomic pathology specimens submitted. To identify system vulnerabilities in specimen collection, processing, analysis, and reporting associated with patient misidentification involving the clinical laboratory, anatomic pathology, and blood transfusion services. A qualitative analysis was performed on 227 root cause analysis reports from the Veterans Health Administration. Content analysis of case reports from March 9, 2000, to March 1, 2008, was facilitated by a Natural Language Processing program. Data were categorized by the 3 stages of the laboratory test cycle. Patient misidentification accounted for 182 of 253 adverse events, which occurred in all 3 stages of the test cycle. Of 132 misidentification events occurring in the preanalytic phase, events included wrist bands labeled for the wrong patient were applied on admission (n = 8), and laboratory tests were ordered for the wrong patient by selec...Continue Reading

References

Sep 3, 2002·Annals of Internal Medicine·Timothy P Hofer, Rodney A Hayward
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Citations

Mar 15, 2014·Biochemia Medica·Mario PlebaniMaria Laura Chiozza
May 3, 2013·Archives of Pathology & Laboratory Medicine·Liron PantanowitzJohn H Sinard
Oct 31, 2021·Clinical Chemistry and Laboratory Medicine : CCLM·Christopher-John L Farrell
Aug 27, 2010·Transfusion·Lawrence T GoodnoughDaniel A Arber
Aug 27, 2010·Vox Sanguinis·S Ansari, A Szallasi
Nov 18, 2010·Clinica Chimica Acta; International Journal of Clinical Chemistry·Loh Tze PingSunil K Sethi
Nov 3, 2010·Clinica Chimica Acta; International Journal of Clinical Chemistry·Tze Ping LohSunil K Sethi

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