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Licensed Unlicensed Requires Authentication Published by De Gruyter December 22, 2008

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics

Giuseppe Lippi , Norbert Blanckaert , Pierangelo Bonini , Sol Green , Steve Kitchen , Vladimir Palicka , Anne J. Vassault , Camilla Mattiuzzi and Mario Plebani

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.


Corresponding author: Prof. Giuseppe Lippi, MD, Sezione di Chimica e Microscopia Clinica, Dipartimento di Scienze Morfologico-Biomediche, Università degli Studi di Verona, Ospedale Policlinico G.B. Rossi, Piazzale Scuro, 10, 37134 Verona, Italy Phone: +39-045-8124308, Fax: +39-045-8201889, ,

Received: 2008-7-16
Accepted: 2009-11-25
Published Online: 2008-12-22
Published in Print: 2009-02-01

©2009 by Walter de Gruyter Berlin New York

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