Patient and Sample Identification. Out of the Maze?

Open access


Background: Patient and sample misidentification may cause significant harm or discomfort to the patients, especially when incorrect data is used for performing specific healthcare activities. It is hence obvious that efficient and quality care can only start from accurate patient identification. There are many opportunities for misidentification in healthcare and laboratory medicine, including homonymy, incorrect patient registration, reliance on wrong patient data, mistakes in order entry, collection of biological specimens from wrong patients, inappropriate sample labeling and inaccurate entry or erroneous transmission of test results through the laboratory information system. Many ongoing efforts are made to prevent this important healthcare problem, entailing streamlined strategies for identifying patients throughout the healthcare industry by means of traditional and innovative identifiers, as well as using technologic tools that may enhance both the quality and efficiency of blood tubes labeling. The aim of this article is to provide an overview about the liability of identification errors in healthcare, thus providing a pragmatic approach for diverging the so-called patient identification crisis.

1. Lippi G, Simundic AM, Mattiuzzi C. Overview on patient safety in healthcare and laboratory diagnostics. Biochem Med (Zegreb) 2010; 20: 131-43.

2. Kohn KT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

3. Lippi G, Plebani M, Graber ML. Building a bridge to safe diagnosis in health care. The role of the clinical laboratory. Clin Chem Lab Med 2016; 54: 1-3.

4. Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med 2003; 18: 61-7.

5. Lippi G, Banfi G, Buttarello M, Ceriotti F, Daves M, Dolci A, et al. Recommendations for detection and management of unsuitable samples in clinical laboratories. Clin Chem Lab Med 2007; 45: 728-36.

6. Plebani M, Astion ML, Barth JH, Chen W, de Oliveira Galoro CA, Escuer MI, et al. Harmonization of quality indicators in laboratory medicine. A preliminary consensus. Clin Chem Lab Med 2014; 52: 951-8.

7. UK National Patient Safety Agency. Safer patient identification. Available at: Last Access: 30 September 2016.

8. Joint Commission. Sentinel Event Data Summary. Available at: Last Access: 30 Sep - tem ber 2016.

9. Henneman PL, Fisher DL, Henneman EA, Pham TA, Cam pbell MM, Nathanson BH. Patient identification errors are common in a simulated setting. Ann Emerg Med 2010; 55: 503-9.

10. Lippi G, Plebani M. Identification errors in the blood transfusion laboratory: a still relevant issue for patient safety. Transfus Apher Sci 2011; 44: 231-3.

11. Acheampong F, Anto BP, Koffuor GA. Medication safety strategies in hospitals-a systematic review. Int J Risk Saf Med 2014; 26: 117-31.

12. Danaher LA, Howells J, Holmes P, Scally P. Is it possible to eliminate patient identification errors in medical imaging? J Am Coll Radiol 2011; 8: 568-74.

13. Nakhleh RE, Zarbo RJ. Surgical pathology specimen identification and accessioning: A College of American Pathologists Q-Probes Study of 1 004 115 cases from 417 institutions. Arch Pathol Lab Med 1996; 120: 227-33.

14. Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clin Lab Med 2004; 24: 979-96.

15. Lippi G, Guidi GC. Risk management in the preanalytical phase of laboratory testing. Clin Chem Lab Med 2007; 45: 720-7.

16. Carraro P, Plebani M. Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem 2007; 53: 1338-42.

17. College of American Pathologists, Valenstein PN, Raab SS, Walsh MK. Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. Arch Pathol Lab Med 2006; 130: 1106-13.

18. Wagar EA, Stankovic AK, Raab S, Nakhleh RE, Walsh MK. Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories. Arch Pathol Lab Med 2008; 132: 1617-22.

19. Harris County Hospital District. Harris County Hospital District Puts Patient Safety in the Palm of Your Hand. Available at: Last Access: 30 September 2016.

20. Joint Commission. 2016 National Patient Safety Goals

2016. Available at Last access: 30 September 2016.

21. Clinical and Laboratory Standards Institute. Procedures for collection of diagnostic blood specimens by venipuncture; approved guideline - 6th ed. CLSI document GP41-A6: 2007. Wayne, PA: Clinical and Laboratory Standards Institute; 2007.

22. van Dongen-Lases EC, Cornes MP, Grankvist K, Ibarz M, Kristensen GB, Lippi G, et al. Patient identification and tube labelling - a call for harmonisation. Clin Chem Lab Med 2016; 54: 1141-5.

23. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Pa - licka V, et al. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med 2009; 47: 143-53.

24. Ajami S, Rajabzadeh A. Radio Frequency Identification (RFID) technology and patient safety. J Res Med Sci 2013; 18: 809-13.

25. Nalla PR, Chalavadi KM. Iris classification based on sparse representations using on-line dictionary learning for large-scale de-duplication applications. Springerplus 2015; 4: 238.

26. Ning HC, Lin CN, Chiu DT, Chang YT, Wen CN, Peng SY, et al. Reduction in Hospital-Wide Clinical Laboratory Spe - cimen Identification Errors following Process Interven - tions: A 10-Year Retrospective Observational Study. PLoS One 2016; 11: e0160821.

27. World Health Organization. WHO guidelines on drawing blood: best practices in phlebotomy. WHO Press, Geneva, Switzerland; 2010.

28. Lippi G, Caputo M, Banfi G, Buttarello M, Ceriotti F, Daves M, et al. Recommendations for collection of venous blood. Biochim Clin 2008; 32: 569-77.

29. Lippi G, Mattiuzzi C, Banfi G, Buttarello M, Caputo M, Daves M, et al. Proposal of a checklist for venous blood collection. Biochim Clin 2013; 37: 312-7.

30. Lippi G, Sonntag O, Plebani M. Appropriate labelling of blood collection tubes: a step ahead towards patient's safety. Clin Chem Lab Med 2011; 49: 1921-3.

31. Piva E, Tosato F, Plebani M. Pre-analytical phase: The auto mated ProTube device supports quality assurance in the phlebotomy process. Clin Chim Acta 2015; 451: 287-91.

32. Xie J, Zhang L, You J, Zhang D, Qu X. A study of hand back skin texture patterns for personal identification and gender classification. Sensors (Basel) 2012; 12: 8691-709.

33. Gomatam S, Carter R, Ariet M, Mitchell G. An empirical comparison of record linkage procedures. Stat Med 2002; 21: 1485-96.

34. Hawker CD, McCarthy W, Cleveland D, Messinger BL. Invention and validation of an automated camera system that uses optical character recognition to identify patient name mislabeled samples. Clin Chem 2014; 60: 463-70.

35. World Health Organization, Joint Commission and Joint Commission International. Patient Identification. Patient Safety Solutions 2007; 1: Solution 2. WHO Press, World Health Organization, Geneva, Switzerland.

36. Graber ML. The IOM report on improving diagnosis: new concepts. Diagnosis 2015; 2: 201-3.

37. Plebani M. Laboratory-associated and diagnostic errors: a neglected link. Diagnosis 2014; 1: 89-94.

38. Lima-Oliveira G, Lippi G, Salvagno GL, Picheth G, Guidi GC. Laboratory Diagnostics and Quality of Blood Co l - lection. J Med Biochem 2015; 34: 288-94.

39. Aykal G, Keşapli M, Aydin O, Esen H, Yeğin A, Güngör F, et al. Pre-Test and Post-Test Applications to Shape the Education of Phlebotomists in A Quality Management Pro gram: An Experience in A Training Hospital. J Med Biochem 2016; 35: 347-53.

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