Source
Kaiser Permanente Medical Center, South San Francisco, California 94080, USA. eric.suba@kp.org
Abstract
PURPOSE:
Patient identification errors in surgical pathology often involve switches of prostate or breast needle core biopsy specimens among patients. We assessed strategies for decreasing the occurrence of these uncommon and yet potentially catastrophic events.
MATERIALS AND METHODS:
Root cause analyses were performed following 3 cases of patient identification error involving prostate needle core biopsy specimens.
RESULTS:
Patient identification errors in surgical pathology result from slips and lapses of automatic human action that may occur at numerous steps during pre-laboratory, laboratory and post-laboratory work flow processes.
CONCLUSIONS:
Patient identification errors among prostate needle biopsies may be difficult to entirely prevent through the optimization of work flow processes. A DNA time-out, whereby DNA polymorphic microsatellite analysis is used to confirm patient identification before radiation therapy or radical surgery, may eliminate patient identification errors among needle biopsies.