Blood and tissue samples sent to the pathology lab at Cork University Hospital regularly have the wrong patient name on the label, according to internal hospital documents seen by the Irish Examiner.
The revelation, contained in the pathology department’s risk register — a management tool to identify and manage risk — says the incorrect labelling, both on the bottle containing the sample and the request form, occurs at the point where the sample is taken. This includes GP surgeries, outpatient clinics, and in hospitals.
Asked by the Irish Examiner to explain how samples are regularly labelled incorrectly, CUH said the pathology department was not the source of the problem. “The issue occurs outside of the pathology environment and is primarily down to mislabelling of samples at the time of sample acquisition,” CUH said.
In other words, the error occurred at the time the blood or tissue samples were taken from the patient and subsequently arrived with incorrect information to the pathology lab.
The hospital said that, to combat the problem, it has monitoring arrangements in place within the laboratory service “to identify this issue when it arises and to deal with it appropriately”.
Control measures outlined in the risk register in January include “education of doctors, nurses, and phlebotomists” — staff trained to draw blood — in this procedure and a built-in lab “safe check” to detect and mitigate the problem.
This safe check includes requesting two samples for blood grouping and checking for historical patient records of blood groups.
The register states there is strict patient identification policy and procedure in CUH for cross-matching blood and other samples.
However, the register also outlines the need for additional measures to counter the mislabelling, including “a campaign directed at laboratory users to increase awareness” and “change behaviour at the point of patient identification”, before the sample is drawn.
John Sheehan, a GP in Blackpool, Cork City, said the mislabelling of samples was something that could easily happen in an environment where staff were overstretched “and trying to do five or six things at the same time”.
“It is quite concerning but I suspect, in situations like that, it’s probably human error, where a doctor takes samples from two different patients and puts them aside to do another task and then gets them mixed up when putting on the labels,” said Dr Sheehan.
Dr Sheehan, who is also a Fianna Fáil city councillor, said that while health professionals “certainly try to minimise errors”, there needed to be structured systems and protocols in place to reduce the risk, as well as further education.
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