A Quality Initiative to Decrease Pathology Specimen Labeling Errors Using Radiofrequency Identification in a High-Volume Endoscopy Center

Abstract

Purpose: Our institution has had problems with mislabeling of tissue specimens in our gastrointestinal and colorectal surgery endoscopy units. Most labeling errors have been due to either the wrong patient label or no label being affixed to a specimen bottle. As a result, an initiative was created to reduce the number of specimen labeling errors. This initiative involved the application of radiofrequency identification (RFID) technology to specimen bottles, moving to a paperless pathology requisition system and confirmation of the correct site, correct patient by both the endoscopy nursing staff and the endoscopist on each specimen bottle. Methods: We reviewed the number of specimen labeling errors from our endoscopy unit for the first three months of 2007, prior to the implementation of the initiative and the first three months of 2008, 6 months after the initiation of RFID specimen labeling with paperless requisition and two provider confirmation of correct site, correct patient specimen labeling. Specimen labeling errors were categorized as Class 1 (only typographical with no potential clinical consequences), Class 2 (minor error, unlikely to have clinical consequences) and Class 3 (significant error that has the potential to detrimentally impact patient care). The Fischer's exact test was used to compare the rate of specimen bottle labeling errors before and after the initiation of this new system. Results: In the first three months of 2007, our endoscopy unit sent 8231 specimen bottles to our pathology laboratory for evaluation and 8539 bottles in the first three months of 2008. There were 646 (7.85%) Class 1 errors in the first quarter of 2007 and 35 (0.41%) in the first quarter of 2008 (P < 0.001). There were 112 (1.36%) Class 2 errors in the first quarter of 2007 and ten (0.12%) in the first quarter of 2008 (P < 0.001). Finally, in the first quarter of 2007 there were seven (0.09%) Class 3 errors and in the first quarter of 2008, there were two (0.02%) Class 3 errors. However, with the new system in place, both Class 3 errors in the first quarter of 2008 were recognized and corrected prior to the processing of the specimens in the pathology laboratory (P= .001). Conclusion: These data suggest that the initiation of a new specimen labeling system that uses RFID technology, a paperless requisition process and confirmation of the correct site correct patient by two health-care providers significantly decreased specimen labeling errors of every level in a high volume endoscopy center.