The Value of Inking Breast Cores to Reduce Specimen Mix-up

Department of Pathology, Baptist Hospital of Miami, Miami, FL 33176, USA.
American Journal of Clinical Pathology (Impact Factor: 3.01). 03/2007; 127(2):271-2. DOI: 10.1309/YX0R8VX8T4EBQVLA
Source: PubMed

ABSTRACT Accidental switching of tissue specimens in the histology laboratory can result in significant medical error. We sought to evaluate inking breast core needle specimens as a method to reduce the chance of specimen mix-up. We sequentially inked 1,000 consecutive breast core specimens with 6 different colors. Review of the color of the ink revealed 3 discrepancies: 1 related to blocks being switched, 1 related to incorrect labeling, and 1 was a typographical error. Inking of breast core specimens is a simple, inexpensive, and effective way to help reduce the chance of specimen mix-up.

  • [Show abstract] [Hide abstract]
    ABSTRACT: The production and interpretation of a haematoxylin-eosin stained slide from a patient specimen is a complex, multi-step process. An error within any of the steps may cause patient harm. The steps in this process can be divided into the pre-analytic, analytic and post-analytic phases. This paper will review benchmarking and published error rates, where available, across all three phases. Practical, evidence-based, methods to reduce errors in all three phases will be discussed with emphasis placed upon the benefits and limits of benchmarking and six-sigma. The concept of striving for zero defects through lean production methods and the Toyota Production System will be discussed as it applies to all three phases of surgical pathology.
    Diagnostic Histopathology 07/2008; DOI:10.1016/j.mpdhp.2008.06.002
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Maintaining patient identity throughout the biopsy pathway is critical for the practice of dermatology and dermatopathology. From the biopsy procedure to the acquisition of the pathology report, a specimen may pass through the hands of more than twenty individuals in several workplaces. The risk of a mix-up is considerable and may account for more serious mistakes than diagnostic errors. To prevent specimen mix-up, work processes should be standardized and automated wherever possible, e.g., by strict order in the operating room and in the laboratory and by adoption of a bar code system to identify specimens and corresponding request forms. Mutual control of clinicians, technicians, histopathologists, and secretaries, both simultaneously and downstream, is essential to detect errors. The most vulnerable steps of the biopsy pathway, namely, labeling of specimens and request forms and accessioning of biopsy specimens in the laboratory, should be carried out by two persons simultaneously. In preceding work steps, clues must be provided that allow a mix-up to be detected later on, such as information about clinical diagnosis, biopsy technique, and biopsy site by the clinician, and a sketch of the specimen by the technician grossing it. Awareness of the danger of specimen mix-up is essential for preventing and detecting it. The awareness can be heightened by documentation of any error in the biopsy pathway. In case of suspicion, a mix-up of specimens from different patients can be confirmed by DNA analysis.
    01/2014; 4(1):27-42. DOI:10.5826/dpc.0401a04


Available from