Re: Histology slide labeling errors

From:Vinnie Della Speranza

Mislabeled slides that make their way to the pathologist set the stage for catastrophe. It cannot be assumed that the pathologist will always be able to spot the labeling error, for example if gyn bxs from two post menopausal women have been confused due to a labeling error.
 aside from this, persistent labeling errors can lose the pathologist's confidence in your lab.
even though 4 mislabelings out of 6000 seems like a small #, someone could have been seriously injured.
we check all stained slides against the original blocks at the time the slides are labeled. the labeled slides are double checked by a second individual before they leave the lab.
individuals who have committed repetitive labeling errors, or if a labeling error led the dept to report a mis diagnosis leads to an employee reprimand according to our facility's disciplinary policy.
I understand that hard working staff make errors. the key is that the error be caught before it leaves the lab. it is not acceptable for the pathologist to have erroneous slides at the microscope.
 
 
 
Vinnie Della Speranza
Manager for Anatomic Pathology Services
Medical University of South Carolina
165 Ashley Avenue  Suite 309
Charleston, SC 29425
Ph: 843-792-6353
fax: 843-792-8974

>>> "Norman, Barbara" <barbara.norman@DSILABS.com> 10/15/02 02:21PM >>>
Would greatly appreciate your comments and any suggestion that you may have
on the issue concerning labeling errors.
Our department does realize that the acceptable level of labeling errors is
zero. We are all aware of the serious problems that can arise if labeling
errors are not addressed. We are very conscientious about providing the
patient with the best service while preserving the patients identity.
Our procedure dictates that slides are labeled at the time of sectioning and
before they are signed out they are rechecked and checked again when the
permanent paper label is applied.
There have been times when the pathologist did receive slides that were
mislabeled. It was brought back into the department and checked and
re-labeled. This error is unacceptable by a few of our pathologists, and my
concern is that they are also responsible to read each label, thus
maintaining another QC review.
Last month the department produced close to 6000 slides and 4 slides were
mislabeled, ( a positive control was labeled negative and the negative was
labeled positive (for IHC).
Please help fellow Histologist, How are you handling these errors at your
institution?

Many thanks,
B.L. Norman
Naples, FL



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