[Histonet] RE: Labeling Errors

[Morken, Timothy]

Laurie, 

The question to ask is, what is ACHIEVABLE with the technology you have in place? The term is ALRA or ALRP...As Low as Reasonably Achievable, or Possible. 

For instance, when we hand-wrote slide labels, and used offline cassette printers we accepted that we would have a rather high rate of human errors. Same with hand-applying labels after staining.

With barcoding, printing cassettes directly from the LIS, printing and applying labels at the microtome our error rate is down by an order magnitude, but occasional errors still occur due to humans "shortcutting"  the system, or faults in the system itself (ie, not flagging duplicate labels scanned). None of those errors are acceptable but we still need to figure out how to design the system to prevent them. 

The papers below give numbers to this problem. The patient ID error without automation came out to 4+ per 1000 specimens. 

The general error rate was/is:
1/100 with all hand-written workflow
1/1000 with LIS printing of cassettes and labels, but human-applied
1/10,000 with barcoding and single piece workflow throughout the system and interfaces to instruments (stainers)

Makary MA et al. Surgical specimen identification errors....  Surgery 2007 Apr;141(4):450-5 
Nakhleh RE, et al. Amended reports ... Q-probes study of 1,667,547 accessioned cases ...  Arch Pathol Lab Med. 1998 Apr;122(4):303-9
Resar RK. Making noncatastrophic health care processes more reliable...  Health Serv Res. 2006; 41:1677-1689.



Tim Morken
Supervisor, Histology, Electron Microscopy and Neuromuscular Special Studies
UC San Francisco Medical Center
San Francisco, CA

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-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Laurie Colbert
Sent: Tuesday, October 14, 2014 10:21 AM
To: Histonet Post (histonet <@t> lists.utsouthwestern.edu)
Subject: [Histonet] Labeling Errors

Is there a national average or benchmark for "acceptable" labeling errors in Histology?

Laurie Colbert HT (ASCP)
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