Errors and Solutions

The pathologist's diagnosis of a tissue sample plays a key role in determining what kind of treatment patients receive, and what sort of outcomes they can expect. But because of errors such as mislabeling and cross contamination, specimens in the lab can be mistaken for those of another patient, leading to misdiagnosis.

The consequences of patient misidentification can include:

False positive diagnoses and costly, unnecessary surgery
False negative diagnoses and inadequate treatment
Lab/hospital liability for misdiagnosis
Litigation against lab/hospital because of misdiagnosis

In one study, Nakhleh et.al.¹ noted that:

In the preanalytic phase of surgical pathology, as tissue specimens are collected, transported, accessioned, dissected, embedded, cut, and placed on slides, there are multiple points where patients tissues are transferred or handed to another person. Specimen identification must be maintained across these hand offs.

_{1: Raouf E. Nakhleh, Michael O. Idowu, Rhona J. Souers, Frederick A. Meier, Leonas G. Bekeris, (2011) Mislabeling of Cases, Specimens, Blocks, and Slides: A College of American Pathologists Study of 136 Institutions. Archives of Pathology & Laboratory Medicine: August 2011, Vol. 135, No. 8, pp. 969-974.}

Slide and Cassette Labeling

Hand labeling creates the potential for errors that can occur at a number of touch points in the pathology lab as a patient's tissue biopsy is processed.

Cross Contamination

In many labs today, the primary staining process is completed manually through "dipping and dunking" slides into shared reagent baths.

Lost Samples

In the diagnostic process, tissue is precious. Going back for more tissue is difficult and sometimes impossible. For this reason, each tissue sample must be closely protected, every step of the journey through the pathology lab.

Generic Treatment

What works for one patient may be ineffective or even harmful for another. In order to build the most effective treatment plan, pathologists need:

The ability to be not only diagnostic, but also prognostic and predictive about how a patient will respond to a particular therapy or drug
The ability to share information with fellow pathologists quickly, in order to gain outside opinions on difficult cases

Slow Turnaround Time

Time is of the essence when it comes to getting tissue biopsy results back to patients.
But pathology labs face obstacles that can impede the delivery of fast, accurate results:

Manual "dip and dunk" staining can compromise the integrity of tissue samples
Hand labeling can lead to sample misidentification
A lack of sample tracking can lead to lost samples

Errors and Solutions

...