TY - JOUR
T1 - Patient misidentification in Papanicolaou tests
T2 - A systems-based approach to reducing errors
AU - Meyer, Erin
AU - Underwood, R. Shawn
AU - Padmanabhan, Vijayalakshmi
PY - 2009/8
Y1 - 2009/8
N2 - Context. - Patient safety is of prime concern in every laboratory. Double labeling of glass slides is performed in many cytology laboratories where handwritten patient information on the frosted portion of the glass is overlaid with paper labels (sometimes containing bar codes). The cytotechnologists match this information by turning slides over. We use SurePath liquid-based cytology for Papanicolaou tests in our laboratory and noticed patient misidentification because of slide labeling errors, a problem that has not been addressed in the literature. Objective. - To reduce slide labeling errors without increasing costs, using a systems-based approach. Design. - All errors from mislabeled slides during November 2006 were documented, and an informal rootcause analysis was performed. Slides were labeled on opposite ends and monitored for errors. Results. - Labeling on different ends of the glass slide reduced our error rate from 0.59% to 0%, made visual matching easy, and did not alter costs. Conclusions. - The practice of overlaying handwritten information with printed labels for liquid-based Papanicolaou tests should be strongly discouraged and replaced with placing patient information in separate portions of the glass slide so that crucial patient identification is not hidden and visual matching is easy.
AB - Context. - Patient safety is of prime concern in every laboratory. Double labeling of glass slides is performed in many cytology laboratories where handwritten patient information on the frosted portion of the glass is overlaid with paper labels (sometimes containing bar codes). The cytotechnologists match this information by turning slides over. We use SurePath liquid-based cytology for Papanicolaou tests in our laboratory and noticed patient misidentification because of slide labeling errors, a problem that has not been addressed in the literature. Objective. - To reduce slide labeling errors without increasing costs, using a systems-based approach. Design. - All errors from mislabeled slides during November 2006 were documented, and an informal rootcause analysis was performed. Slides were labeled on opposite ends and monitored for errors. Results. - Labeling on different ends of the glass slide reduced our error rate from 0.59% to 0%, made visual matching easy, and did not alter costs. Conclusions. - The practice of overlaying handwritten information with printed labels for liquid-based Papanicolaou tests should be strongly discouraged and replaced with placing patient information in separate portions of the glass slide so that crucial patient identification is not hidden and visual matching is easy.
UR - http://www.scopus.com/inward/record.url?scp=69149108167&partnerID=8YFLogxK
M3 - Article
C2 - 19653729
AN - SCOPUS:69149108167
VL - 133
SP - 1297
EP - 1300
JO - Archives of Pathology and Laboratory Medicine
JF - Archives of Pathology and Laboratory Medicine
SN - 0003-9985
IS - 8
ER -