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Lost, Mislabeled, and Unsuitable Surgical Pathology Specimens

Nakhleh, Raouf E. MD

doi: 10.1097/01.PCR.0000065693.59517.7E

Discussion of errors usually focuses on the analytic portion of the test cycle. In this article, preanalytic errors are discussed. Preanalytic errors range from simple, possibly inconsequential omissions such as the date of biopsy to serious loss of specimens or misidentified specimens. To portray the current status of preanalytic systems in surgical pathology, four illustrative cases of preanalytic errors are presented, and necessary steps for accurate specimen collection, labeling, and delivery to the laboratory are described. Although total preanalytic errors range to as high as 6% of surgical pathology cases, the percent of errors that may potentially lead to patient harm is not known. To reduce preanalytic errors effectively, a broad effort is necessary, because preanalytic errors originate where specimens are collected. The place of collection varies widely, from standard operating rooms to outpatient surgical centers and remote doctors’ offices. Therefore, successful efforts have implemented wide-ranging marketing techniques to educate and impress upon the medical staff throughout an institution, and at the same time have adopted stringent standards for specimen collection, labeling, and delivery.

From the Department of Pathology, Mayo Clinic Jacksonville/St. Luke’s Hospital, Jacksonville, FL.

Address correspondence and reprint requests to Raouf E. Nakhleh, MD, Department of Pathology, St Luke’s Hospital/Mayo Clinic Jacksonville, 4201 Belfort Rd., Jacksonville, FL 32216. E-mail:

© 2003 Lippincott Williams & Wilkins, Inc.