Identification and Correction of Errors in the Anatomic Pathology Gross Room

High-volume pathology laboratories have occasional incidents of specimen mixup. This case report describes one such incident, in which there was an error in specimen accessioning. The current system has various checks to catch potential errors. The error was detected; however, the case had been signed out the previous day. We performed a root cause analysis to assess the sequence of events and identify all possible sources of errors. In addition an inservice was done with the surgical pathology laboratory staff. It served to provide feedback regarding workflow issues that impact technical staff working and could potentially result in errors. Finally, corrective measures were implemented.