1Clinical Chemistry Laboratory, University of Verona, Verona, Italy, EPSC – European Preanalytical Scientific Committee (www.specimencare.com) and International Federation of Clinical Chemistry Working Group on Patient's Safety
2EPSC – European Preanalytical Scientific Committee (www.specimencare.com) and Laboratory Medicine, University Hospital Leuven, Leuven, Belgium
3EPSC – European Preanalytical Scientific Committee (www.specimencare.com), International Federation of Clinical Chemistry Working Group on Patient's Safety and Clinical Biochemistry, School of Medicine, University Vita-Salute San Raffaele, Milano, Italy
4EPSC – European Preanalytical Scientific Committee (www.specimencare.com) and BD Diagnostics – Preanalytical Systems, New Jersey, USA
5EPSC – European Preanalytical Scientific Committee (www.specimencare.com) and Sheffield Hemophilia and Thrombosis Center, Royal Hallamshire Hospital, Sheffield, UK
6EPSC – European Preanalytical Scientific Committee (www.specimencare.com) and Institute of Clinical Biochemistry and Diagnostics, Charles University, Medical Faculty and University Hospital, Hradec Kralove, Czech Republic
7EPSC – European Preanalytical Scientific Committee (www.specimencare.com) and Laboratoire de Biochimie B, Hôpital Necker Enfants Malades, APHP, Paris, France
8Direzione Medica, Azienda Ospedaliera di Verona, Verona, Italy
9International Federation of Clinical Chemistry Working Group on Patient's Safety and Department of Laboratory Medicine, University of Padova, Padova, Italy
Abstract
Laboratory diagnostics, a pivotal part of clinical decision making, is no safer than other areas of healthcare, with most errors occurring in the manually intensive preanalytical process. Patient misidentification errors are potentially associated with the worst clinical outcome due to the potential for misdiagnosis and inappropriate therapy. While it is misleadingly assumed that identification errors occur at a low frequency in clinical laboratories, misidentification of general laboratory specimens is around 1% and can produce serious harm to patients, when not promptly detected. This article focuses on this challenging issue, providing an overview on the prevalence and leading causes of identification errors, analyzing the potential adverse consequences, and providing tentative guidelines for detection and prevention based on direct-positive identification, the use of information technology for data entry, automated systems for patient identification and specimen labeling, two or more identifiers during sample collection and delta check technology to identify significant variance of results from historical values. Once misidentification is detected, rejection and recollection is the most suitable approach to manage the specimen.
Clin Chem Lab Med 2009;47:143–53.
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