Quality Improvement: Reduce Specimen Labeling Errors

Editor's Note

Surgical procedures frequently produce specimens for pathology to confirm diagnosis and ensure quality control. However, common errors such as look-alike sound-alike specimen labeling inaccuracies can compromise patient safety and negatively impact workflow efficiency, as discussed in an October 28 improvement brief in the Joint Commission Journal on Quality and Patient Safety. The brief reported on a quality improvement initiative by clinicians working at a women’s and children’s hospital in Singapore to reduce mislabeling of endometrial versus endocervical curettings. They found that the most frequent specimen error in the facility was attributed to look-alike sound-alike specimen labelling. Following a root cause analysis, these clinicians engaged in a 2-year quality improvement initiative that resulted in successfully reducing specimen labelling errors.

The multifaceted improvement approach they reported on to reduce specimen labeling errors included four strategies. First, the team engaged a pilot system-level enhancement to the electronic ordering interface. Next, they facilitated clinician education, training, and monthly feedback. In the second phase of the project, they initiated a team-based process to redesign practices that emphasized accountability and safety culture. Lastly, they engaged a subsequent system-level enhancement to the electronic ordering interface, per the report.

To measure success with this improvement initiative the clinicians tracked a total of 42,968 curettings from January 2020 to May 2025. Mislabeling rates were 3.79 per 1,000 orders at baseline in January–May 2020 and 0.13 in the final phase of the improvement initiative. They reported 30 consecutive zero-error months after implementing interventions. The clinician authors documenting these improvements suggested that successfully reducing look-alike sound-alike specimen errors was due to a combination of team education, feedback, process audits, and interface redesign.