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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 9/27/2020 12:00:00 AM
Country: South Korea
This alert describes three cases of mismanagement of tissue and cell pathology samples (switched samples, lost samples, errors in barcodes) that led to suboptimal and potentially harmful care management. The alert includes recommendations to prevent recurrence, precautions to take before/during/after sample collection, and precautions for receiving and labelling samples.


Environment / Equipment
  1. Establishment of a computerized control system for preventing loss of samples
Rules / Policies / Procedures
  1. Preparation and compliance with guidelines on sample management for safe sample acquisition and accurate test results
  2. Compliance with precautions before, during, and after collection of samples
  3. Compliance with precautions for receiving and labeling samples

Errors in management of tissue and cell pathology samples