RT Journal Article
SR Electronic
T1 How many mislabelled samples go unidentified? Results of a pilot study to determine the occult mislabelled sample rate
JF Journal of Clinical Pathology
JO J Clin Pathol
FD BMJ Publishing Group Ltd and Association of Clinical Pathologists
SP jcp-2024-209544
DO 10.1136/jcp-2024-209544
A1 Raymond, Caitlin
A1 Dell’Osso, Liesel
A1 Guerra, David
A1 Hernandez, Julia
A1 Rendon, Leonel
A1 Fuller, Donna
A1 Villasante-Tezanos, Alejandro
A1 Garcia, JuanDavid
A1 McCaffrey, Peter
A1 Zahner, Christopher
YR 2024
UL http://jcp.bmj.com/content/early/2024/05/20/jcp-2024-209544.abstract
AB Background Specimens with incorrect patient information are both a critical safety error and difficult to identify. Estimates of sample mislabelling rely on subjective identification of mislabelling, with the possibility that not all mislabelled samples are being caught.Methods We determined the blood type of two or more complete blood count specimens with the same patient label and assessed for discrepancies. We additionally determined the rate of identified sample mislabelling for the study period.Results We found a rate of 3.17 per 1000 discrepancies over the study period. These discrepancies most likely represent occult, or unidentified, mislabelled samples. In contrast, the rate of identified sample mislabelling was 1.15 per 1000.Conclusions This study suggests that specimens identified as, or known to be, mislabelled represent only a fraction of those mislabelled. These findings are currently being confirmed in our laboratory and are likely generalisable to other institutions.