The Effectiveness of Inking Needle Core Prostate Biopsies for Preventing Patient Specimen Identification Errors: A Technique to Address Joint Commission Patient Safety Goals in Specialty Laboratories (Report)
The elimination or reduction of medical errors has been a main focus of health care enterprises in the United States since the publication of To Err Is Human: Building a Safer Health Care System by the Institute of Medicine in 2000. (1) Makary et al (2) recently quantified the “incidence and type of specimen identification errors in a surgical patient population.” Elimination of errors in patient and specimen identification is a key component of this focus and is the number one goal in the Joint Commission’s 2008 National Patient Safety Goals Laboratory Services Program. (3) The processing of anatomic specimens within the pathology laboratory is under the direct control of the pathologist, and all necessary steps must be taken to ensure that specimens are not inadvertently transferred from one patient to another. Good pathology practice suggests that similar specimen types should not be processed in sequential order. However, laboratories such as ours that specialize in a certain type of specimen, such as prostatic needle biopsies, have no choice but to process grossly and microscopically similar specimens sequentially. We noted a report by Renshaw et al (4) on their experience in inking breast biopsy core specimens to avoid specimen mix-up.
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