Vol. 21 • Issue 5 • Page 30
Mislabeled specimens in pathology have presented serious issues in providing accurate diagnoses and proper patient care-not to mention legal actions and costly settlements. There are literally billions of anatomic pathology (AP) laboratory tests and assays performed annually. A major task is to be sure that all specimens are labeled correctly and able to be successfully tracked.
Not only is the mislabeling a critical issue, but the retrieval and traceability of paraffin blocks and microscopic slides also have presented major issues. Vendors and scientific companies have recognized some of the problems that we face in pathology laboratories and have assisted with technologies to reduce mislabeling/errors.
The need to barcode the AP processes, in particular, is continuing to evolve. The challenge is to correctly label, process and trace laboratory specimens (cytology, histology, electron microscopy, molecular, scanning, archiving) from the patient to the microscope and beyond. The need for economical, accurate and cost-effective technology/systems must provide both effective and efficient methods, which is critical to patient care more now than ever before.
Checks and Balances
Histotechnicians and histotechnologists have explored many methods to establish better accuracy in labeling tissue blocks and slides. Laboratories have implemented “check” systems to ensure patient accuracy through the process such as matching blocks and slides after staining and with logs before leaving the laboratory. For high-volume laboratories, this process is time-consuming and cumbersome.
As well, the process of either handwriting the tissue cassettes and slides, illegible handwriting or inaccurate matching of slides and blocks have all failed in some manner. Technologists do not purposely set out to deliver improperly prepared or mislabeled slides; instead, this is a result of sometimes poorly designed workflow or processes. Patient safety also plays a vital role in this process and has been a primary focus in healthcare. The immediate resolution is both technology and a system to properly label, track and retrieve paraffin blocks and slides with a smooth transition of daily workflow into accurate patient care. The process cycle must have a “closed” system approach to avoid any loop holes.
Barcoding and tracking can provide positive patient identification of tissue specimens from the initial receipt into the pathology grossing room to the microscope. It also can streamline the workflow process and reduce errors. The pathology information systems must be integrated to properly allow the set-up and workflow to work effectively and efficiently.
Since errors can begin at the clinic or surgery level, advance to the grossing/laboratory level, then on to the microscopic level, one of the initial steps to help with labeling errors is to standardize the workflow and processes. For example, specimen labeling errors can begin in the gross room with incorrectly labeled tissue specimens and cassettes, specimen or tissue “part type” or requisition. The cassettes can be illegibly written, placed with the wrong tissue specimen or accidentally picked up from another specimen that is close by or lined up together. When the slides are prepared either singly or in “batch” methods the wrong block and/or slide can be picked up, cut and stained; if the error is not caught the pathologist can sign out the wrong case.
Barcode and tracking can restructure the patient identification by using accurate technology and software applications. This not only standardizes but also improves efficiency, cost savings and patient safety. Hardware and software can be put in place to automate many manual processes. Labs must seriously evaluate their workflow, as it may have been designed and implemented when laboratory work volumes were low and turnaround times were not critical. And with the increased need to better utilize our labor force in the labs, efficient workflow and automation have to be implemented.
The Bar Codes
Barcode technology can use either printed barcode labels or imprinted/embossed bar codes directly onto the cassette or slide. Barcode labels require special chemical resistance adhesives so they do not come off during processing and staining. Also, by applying the barcode labels, the human touch and manual process is still required, potentially introducing error.
The overall best method of using barcode technology in pathology, therefore, is to directly imprint or emboss the barcode onto the cassette or slide. The barcode technology can improve efficiency, reduce manual labor and positively change the workflow. Almost all phases of histology processes would be affected (but improved) to decrease interruptions and produce smooth, error-free specimen progression through the laboratory. Barcodes will improve every identification and labeling process after accessioning.
One of the key factors in making the barcoding technology work the best is integration with the information system. The strength and support of the laboratory information system (LIS) is critical. Depending on the barcode technology, the software may have to be written, tested and implemented. Keep it simple. To help make the process work well, a team of histotechnologists, pathologist assistants, accessioners, transcriptionists, cytotechnologists and pathologists/residents must be created to study, test and implement the barcode process along with the LIS staff. All parties must have input.
The selection of a barcode technology and system must also be studied. The team must decide if barcode labels or direct barcode imprinting will meet the barcode and tracking needs of the laboratory. The barcodes should be able to track specimens, blocks and slides not only to a physical location, but also for the discard process. Hardware should be reviewed to determine the specific needs such as hand-held barcode scanners or wireless devices. How will the hardware work at the grossing station, the embedding center or microtome? No single system will accomplish all scanning and retrieval processes; modifications of hardware and software may have to be designed. The purpose and need for barcode implementation must be thoroughly explored by the team.
As well, all aspects of the pathology department should be considered. Automation should include the gross room-where the laboratory process for tissue specimens begins after removal from the body. Real-time or immediate printing of the cassettes with imprinted/embossed barcodes on the cassettes at the grossing station (to begin the process of error reduction) should be explored. Each step of the histology laboratory is affected by barcode technology-embedding, microtomy, staining and final microscopic slide distribution and retrieval. The patient identification should be secure and accurate, errors reduced and more efficient workflow results.
Another method of tracking is radio-frequency identification (RFID) technology. As its names suggests, it uses a wireless radio-frequency electromagnetic field to transfer data from a tag or label to an object. This tag/label does not need to be within the immediate distance of a scanner but can be detected a great distance away.
The justification of barcode and tracking technology, along with the implementation, can be supported with several reasons:
1. The cost can be a significant reduction in laboratory overhead.
2. Barcode and tracking technology will improve patient safety and care.
3. Barcode and tracking can actually “track” blocks and slides.
M. Lamar Jones is with the Pathology Department, Emory University Hospital, Atlanta, and HT program director, School of Histotechnology, Davidson County Community College, Lexington, NC.