Establishment of measures to prevent errors in the pathology laboratory with the relocation to a new hospital

Abstract

Incidents and accidents cannot be easily avoided in a pathology department because the pathologic specimen preparation process involves many steps that are mostly done manually. Misidentification of a pathologic specimen directly leads to misidentification of a patient or medical malpractice and has a considerable impact on both the patient and the medical practitioner. With the relocation to a new hospital in May 2019, both hardware and system aspects were reviewed to minimize errors in various steps of surgical specimen processing, namely, specimen reception, dissection, embedding, sectioning, staining, and confirmation. In histopathologic specimen processing, which requires considerable manual work, double-checking at each step is important as a measure to prevent mistakes. Since the operating room and the pathology laboratory are adjacent to each other, double-checking at the time of specimen submission to clinics and our department has become possible. In addition, bar code management has been introduced, and improvements have been made in the system so that images of the cut sample can be easily confirmed in each step of specimen processing. As a result, all these measures taken were effective in preventing specimen sampling errors that could lead to medical accidents, producing highly accurate specimens, improving the working environment, and shortening the working time.