Internal Labeling Errors in a Surgical Pathology Department: A Root Cause Analysis

Abstract

To use statistical and root cause analysis to clarify relationships between labeling errors and causal factors in an anatomic pathology gross room and to identify potential solutions. Retrospective analysis was performed on quality-assurance records of Associated Regional and University Pathologists (ARUP) Laboratories/University of Utah Department of Pathology between July 2009 and April 2011. Eighty-five errors had occurred among the 45,000 cases processed over the study period. A total of 27.0% of errors were committed by residents, although they processed only 5.5% of cases. Errors were associated with case complexity. Root cause analysis identified the mechanical cassette labeler, the size and layout of the gross room, and process standardization as areas requiring improvement. Labeling errors in an anatomic pathology laboratory appear to be endemic and show an association with case complexity, employee type, and certain time periods. Root cause analysis suggested improvements in equipment, standard practices, employee training, and design of the laboratory space.