On February 23, 2010, The College of American Pathologists posted an article on its web site titled, "When a Rose Is Not a Rose." The article discusses the problem of mislabeled specimens and the procedural improvements that can be made to prevent labeling errors.
The article explains that "...reporting a wrong result can have potentially devastating effects on the patient. This can be doubly true if there is a patient identification mix-up: one patient could receive the wrong medical or surgical treatment while another doesn't get the treatment he or she needs. Either situation can result in severe, irreversible consequences." As a remedy to the various types of labeling errors it covers, the article offers several procedural improvements such as reviewing definitions, guidelines and the protocol for what to do when an error is detected.
As discussed in previous posts, procedural improvements can go a long way in the effort to reduce labeling errors but the question remains, "What happens when these processes fail?". The "best practices" suggested in this article spend a great deal of time discussing what to do when an error has been detected, how to remedy the error and how to learn from the error. However, the article does not discuss the prevention of adverse patient consequences that may result when a patient identification error remains undetected, even when these improved quality assurance practices are in place.
The know error® specimen security system, introduced in the spring of 2009 by Diagnostic ID, LLC, was designed to not only detect these types of medical switching errors but to prevent the potential resulting misdiagnoses of patients. The know error® system utilizes bar code technology and DNA confirmation testing to detect identification errors and dramatically reduces the likelihood of any resulting adverse patient outcomes. This patent-pending system delivers the benefits of greater patient safety and improved diagnostic accuracy while reducing risk to all involved in the biopsy process.
For more information about the know error® specimen security system with unique patient code and DNA confirmation, please visit our web site www.knowerror.com.
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