AJLM2403 - CME/CMLE - Lost, mislabeled, and mishandled surgical and clinical pathology specimens: A systematic review of published literature-Lost, mislabeled, and mishandled surgical and clinical pathology specimens: A systematic review of published literature

Lost, mislabeled, and mishandled surgical and clinical pathology specimens: A systematic review of published literature

Pdf Summary

The systematic review by Heather J. Carmack and colleagues analyzes existing academic literature on the incidence and handling of lost, mislabeled, and mishandled surgical and clinical pathology specimens during the preanalytical stage. Spanning 1990 to 2021, the authors identified 1313 articles and ultimately included 44 peer-reviewed studies for detailed evaluation. The majority of these studies originated from US-based facilities, with only a few from other countries like Australia and India.<br /><br />Key findings emphasize the limited research on this critical issue, averaging about two articles per year. Most studies (61.3%) focused on mislabeling errors, while others addressed lost or missing specimens (18.2%) and some covered a combination of errors (20.5%). Interventions reported in several studies (22.7%) showed promising results, with error reductions between 70% and 100%, yet detailed methodologies for implementation were often lacking.<br /><br />Pathology specimen errors are significant because they can adversely affect patient care, leading to additional costs, lost time, and potential misdiagnoses. The Joint Commission’s 2024 National Patient Safety Goals for Laboratory Services highlight the importance of correctly identifying patients and improving staff communication to mitigate such errors.<br /><br />The authors categorized articles into empirical studies, case studies, and commentary, with empirical studies being the most common (32 out of 44). These studies utilized various methodologies, including incident reports, Q-Probes analysis, and DNA testing. Incident reports often lacked sufficient time frame consistency, making it challenging to gauge error prevalence accurately.<br /><br />For interventions, most studies highlighted the use of multiple strategies, including education, checklists, improved workflows, new protocols, and technology-based solutions like electronic barcoding systems. However, detailed reports on how to implement these interventions, particularly training and education aspects, were sparse.<br /><br />The authors concluded that there is a strong need for more systematic research and comprehensive reporting of QI interventions related to pathology specimen errors. Addressing these gaps is critical as more states are mandating the reporting of irreplaceable specimen losses as serious reportable events.

Keywords

pathology specimen errors

preanalytical stage

mislabeling errors

lost specimens

clinical pathology

error reduction

patient safety

interventions

systematic review

incident reports