HospitalInspections.org

Based on review of facility policies, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to adhere to their provisions for proper receipt and reporting of tissue specimens for one out of 10 medical records reviewed.
Findings include:
On October 19, 2022, review of facility policy titled "Specimen Processing in Latrobe Pathology Gross Room from Accessioning thru Grossing, Specimen Clean Up and Specimen Disposal", last revised May 2022, revealed "...13. Surgical Procedure...Technical staff must work on one case at a time. Tech must place the printed label on the correct specimen part...".
On October 19, 2022, review of MR1, post operative visit on 09/27/2022, revealed "...Final pathology showed the lesions to contain granulomatous disease. On internal review within the pathology department there was a labeling error of her initial navigational biopsy pathology specimen which at that time showed non-small cell lung cancer.".
Review of written notification form sent to patient revealed "...Type: Mislabeled Specimen...".
On October 19, 2022, at 11:30am, when asked where they believe the error occurred in processing the samples, EMP3, EMP4, and EMP5 all agree they believe it occurred during the transfer to cassettes. Due to two samples being processed at the same time, the accession number would have only been off by one number at the end, and it is believed, in a haste to complete the samples, the numbers were not fully compared.
On October 19, 2022, at 2:04pm, EMP3 was asked about policy " Specimen Processing in Latrobe Pathology Gross Room from Accessioning thru Grossing, Specimen Clean Up and Specimen Disposal " and if it referred to and included cytology specimens. EMP3 confirmed that the policy section outline did include cytology samples.