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 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.