CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Block and slide labeling
“Visuals to the fore in new histology labeling guideline” (June 2015) discusses the CAP/NSH panel’s recommendations on histology labeling in a more nuanced way than the materials on this subject published in Archives of Pathology & Laboratory Medicine. The CAP TODAY article emphasizes difficulties in the guideline’s implementation from financial, logistic, and privacy aspects.
The Eindhoven original root cause analysis model with its human, organizational, and technical categories is most suited to the implementation in practice of the advancements we have seen in histology blocks and slides labeling. Contrary to the investigative root cause analysis, which is more or less an effective reaction to a current event of identification failure, the Eindhoven model, used in chemistry, aviation, and transfusion medicine error prevention, gives a blueprint for comprehensively implementing policies. It requires proactive managerial efforts.
Dr. Brown emphasizes that the panel was not trying to be proscriptive in developing the guideline. As the first step, this might be right, but by limiting recommendations to only patient identification, the guideline lacks a comprehensive approach. I would agree with Vincent Della Speranza’s comment that there are no significant reported data that a lack of labeling standardization has created problems in the histology laboratory. In my experience at the grossing table, rather than a specimen mixup between patients, the more frequent problem is misidentification of and near-miss events related to specimen parts (skin biopsies especially, as well as in prostate, gastroenterology, and gynecology biopsies) during sampling. Although there is a “real estate” issue on the block, the technical difficulties of placing a barcode chip on different specimen parts would be solved by software designers if the problem were addressed. When I only mentioned barcoding in the 2008 article “Root cause analysis of specimen misidentification in surgical pathology accession and grossing,” published in Laboratory Medicine, as the next step in root cause analysis technical category development, I could not have imagined it would now be commonplace. I hope the interval between guideline revisions will be shorter than four years and the recommendations will be made more comprehensive.
Izak B. Dimenstein, MD, PhD, HT(ASCP), Grand Rapids, Mich.