Types of errors include:
(1) specimen not labeled
(2) empty container
(3) no or incorrect laterality
(4) no or incorrect tissue site
(5) incorrect patient name
(6) no patient name
(7) more than one specimen in the container
Errors may involve 1, 2 or multiple patients.
The first step is to investigate – to specify the problem, the number of patients involved and the people involved.
If the identity of the specimen can be determined with a high probability (problem with specimen but in a properly labeled biohazard bag) then it may be acceptable to have the container labeled by the person responsible.
If a specimen can be easily recollected, then:consider discarding the current specimens and recollect.
If a specimen cannot be easily recollected, then clarify the problem.
(1) Distinct specimens in distinct containers.
(2) Specimens from two patients in the same container.
Options:
(1) Do forensic identification on the specimen.
(2) Consider testing both. If both similar then clinically there may not be a need to proceed..
The final step is to obtain closure.
(1) Document what happened.
(2) Make sure that clinicians involved have been informed.
(3) Cancel and credit tests as appropriate. If the decision is to recollect then be sure to re-order.
(4) Consider patient disclosure if appropriate.
(5) Notify the legal department if appropriate.
