The Mislabeling Problem

One of the most common problems affecting patient safety in the clinical laboratory is the receipt of samples that are mislabeled. Despite all the advances in analytical performance, informatics and so on, it seems that getting the right name on the sample in a consistent fashion still eludes the healthcare enterprise. Why is this? Frequently the problem begins at the time of specimen collection when the phlebotomist is required to match a sample with the patient's name. This kind of task invariably poses the risk of human error. So many problems can arise in this situation including carelessness, haste, language difficulties between the patient and the phlebotomist etc. Even the use of bar coding of patient wristbands for automated reading by label printers does not seem to totally eliminate the risk. In the laboratory itself, there are ample opportunities for specimens and patient names to become decoupled. Surgical pathology slides can be labeled with the wrong patient identifier with potentially serious results for patient safety. Perhaps the area that poses the greatest immediate risk is the blood bank. There are few procedures that the clinical laboratory can perform that have greater potential to immediately jeopardize patient health than administration of an incorrect blood unit. It seems that if a choice of labs is to be made for implementing newer methods to eliminate the mislabeling problem, the blood bank should be among the highest priorities.