Requests for Pathologic Evaluation

Patient Identification

“ There is no point in getting the right answer on the wrong patient. It's worse than no answer at all. ” P aul N. V alenstein , MD

Incorrect linkage of a patient to a specimen can lead to serious errors in diagnosis or a failure to diagnose. Correct patient identification is one of the seven Hospital National Patient Safety Goals of TJC. The patient identification provided with specimens must include, as a minimum, two forms of patient identification such as the patient's full name (first and last name), gender, and age or date of birth. Preferably, a unique hospital or clinic identification number is also provided. The patient's room number or location cannot be used as an identifier, as this information is transient and frequently changes.

Identifying information must be attached firmly to the specimen container as a specimen label. Unattached information is easily displaced from an unlabeled container and is not acceptable for definitive identification.

Inappropriately identified specimens must be brought to the attention of the submitting clinician immediately. If there is any uncertainty in determining the correct patient, the clinician should personally identify the specimen. If the nature of the specimen is such that gross identification is not possible (e.g., a small biopsy), and identification is uncertain, a repeat specimen should be obtained if possible. There are tissue typing methods that can match tissues from patients and specimens, but such techniques are time consuming and costly and are best avoided by ensuring appropriate identification at the time of performing the biopsy (see Chapter 3 , The Histology Laboratory, “Identification of Tissue”).

A reduction in labeling errors can be achieved by standardizing specimen labels, using printed labels, and organizing multidisciplinary teams to facilitate communication among clinicians and pathologists. There has been interest in using new technology, such as bar codes, to reduce labeling errors but implementation increases cost and they have not yet been shown to be superior to staff education.

Identification of the Individual(s) Requesting the Examination

The names of all clinicians caring for the patient must be provided in order for these individuals to receive a copy of the final report. This includes not only the physician sending the specimen (e.g., a surgeon or gastroenterologist) but also the primary care physician and other involved specialists (e.g., an oncologist caring for a cancer patient). If a rush reading is requested, the name or names of physicians to be contacted as well as a means to reach them must be provided (e.g., a pager number or telephone number).

Procedure Date

The date of the procedure (day, month, and year) must be documented to:

• Correlate the biopsy findings with other clinical tests (e.g., radiologic examinations or serum chemistries).

• To determine if there is a delay during transport to the pathology department.

• To monitor turn-around-time for pathology specimens.

• To fulfill requirements of Medicare/Medicaid and other third party payers for billing purposes.

The time the specimen was removed from the patient is helpful to determine the length of time prior to fixation, as this “cold ischemic time” can affect the results of some ancillary studies if very prolonged. If the specimen is placed in a fixative for which the time of fixation is important (e.g., bone marrow biopsies in Zenker's fixative; formalin fixation for breast carcinoma specimens that will be used for immunohistochemical studies for hormone receptors and HER2), the time of placing the specimen into fixative should also be recorded. Very short and very prolonged times in fixative can also alter the results of some special studies.

Adequate Clinical History

As for all medical consultations, the consultant can provide the most helpful additional information when adequate history is provided. Clinical history can be essential for some diagnoses, provides a safety net to prevent error (e.g., identifies tissue alterations due to treatment that mimic malignancy), and helps define the need for, and nature of, additional special studies. It has been shown that pathologists cannot accurately predict clinical information from the glass slides alone. Important elements of clinical history for each organ and site are listed at the beginnings of chapters.

TJC requires that information such as race, ethnicity, or family history be included if important for accurate interpretation or reporting of results.

Pertinent clinical history includes: