Identification (ID) Errors: Scope of the Problem

Identification (ID) errors are a concern in all laboratories and are defined as any incongruity between the patient and specimen information and the corresponding labeled specimen. Errors can occur for many reasons, such as variable inputs, process inconsistencies, and human error.

Specimen ID errors can be difficult to study systematically, since many may go undetected or may be underreported. The number of errors reported may in fact depend more on how diligently those errors are tracked and documented than real occurrence rates. Thus, the institution with the lowest error rates may simply be the one that does the poorest job of tracking and reporting errors.

Despite the inherent difficulty in finding accurate numbers, we will examine some case studies to get an idea of the impact of detected errors on patient outcomes. Some studies have estimated that approximately 1% of all surgical pathology cases have some type of error. Fortunately, not all errors lead to patient harm, but some studies have found that approximately 6% of all detected errors have led to some patient harm. For example, in one Johns Hopkins study on surgical specimen identification, it was found that the average preexamination ID error rate alone produced approximately 182 mislabeled surgical specimens per year. When they correlated this error rate with findings of actual patient harm, it was discovered that about 39–45% of these preexamination errors were associated with patient harm.¹