Reduce Diagnostic Error at the Frontline: A Clinician’s Call for Reliable Testing Solutions
By Dr. Amar S. Bhogal
In clinical practice, no moment is more pivotal than the point of diagnosis. We rely these days on the accuracy of blood tests to support diagnosis and patient management. Yet, pre-analytical errors compromise the integrity of that diagnosis —errors in the process such as blood sample collection, labelling and processing. A recent article by the BBC underscores how systemic failures in testing can have devastating consequences for patients with delayed or incorrect results undermining trust and care alike [1].
As a frontline clinician, I’ve seen first-hand how overburdened healthcare systems, staffing challenges, and manual workflows combine to create a perfect storm for sample mislabelling and diagnostic inaccuracy. These are not theoretical risks—they are daily realities that clinicians face.
The reports of incorrect results and high serum potassium levels suggests that the labs are overwhelmed by large numbers of tubes that need re-labelling. It is a little known fact that over 50 million blood tubes are re-labelled each year in the UK when they arrive in the labs. This is because the labels applied at the time of phlebotomy cannot be read by the analyser. Many labs have to re-label 10 000 to 15 000 tubes/day. With this volume of tubes arriving, the only way the labs can cope is to stabilize the tubes to prevent potassium leaking from the erythrocytes. If this step is delayed or omitted, then severe delays lead to high potassium levels, or normalisation of a low potassium – so that the clinician who ordered the blood test is unaware of the perilous state of hypokalaemia – potentially more harmful and much more common than hyperkalaemia. The solution is the right label at the time of phlebotomy, ONE label, ONCE. No stabilisation, no re-labelling and full tracking from start to finish.
The Evidence of Harm
Wrong Blood in Tube (WBIT) incidents, where samples are mislabelled with the wrong patient’s details, remain among the most serious of these threats. In a recent investigation, the Healthcare Safety Investigation Branch (HSIB) highlighted systemic contributors to WBIT—such as insufficient staffing, workflow design, and unsafe shortcuts during sample labelling [2]. According to SHOT data, 792 such near-miss events occurred in a single year, and these are just the ones we know about [3].
Compounding this is the challenge of haemolysis—a key pre-analytical error where red cells rupture, potentially skewing test results. Haemolysis is the single most common cause for sample rejection in clinical labs [4], and research shows that even mild haemolysis can significantly impact analyte measurement [5].
A Scalable Solution
At Salutare, we’ve introduced a sample collection solution that addresses one of the most error-prone steps in the testing pathway: manual relabelling. Our digital phlebotomy system has demonstrated a 90% reduction in sample relabelling—streamlining accuracy at the moment the sample is taken. This isn’t just a technical upgrade; it’s a clinical safety measure. Every reduction in relabelling is a reduction in risk. With the software it is easy to identify and audit the pathway of a blood sample the moment it is taken to the arrival in the lab. With ONE Testing you can print labels at the bedside and should anything go wrong you can identify specific contributors (problematic printers, phlebotomists with higher-than-average haemolysed samples, delays in the arrival of the sample to the lab).
In a 2009 study, it was shown that most lab errors occur in the pre-analytical phase—accounting for up to 70% of total laboratory errors [6]. Another multi-centre study from 2015 confirmed that standardization and automation, particularly around labelling and patient identification, can yield significant safety improvements [7].
Histopathology, too, is not immune. A 2023 study on specimen labelling errors in pathology services reinforced how even rare mislabelling incidents can have significant diagnostic consequences [8].
Moving Forward: From Policy to Practice
The HSIB rightly recommends implementing closed-loop electronic systems that integrate patient identification and sample labelling [2]. But for that to happen, we must champion practical tools that embed safety into the everyday workflow of clinical staff.
Healthcare teams do not need more protocols—they need support. The technology exists. The data is compelling. What’s required now is system-wide commitment to integrating these innovations where they are needed most: at the patient’s side.
References
BBC News. Delayed test results caused serious harm and death. 2024. Available from: https://www.bbc.co.uk/news/articles/cvge00z835do
Healthcare Safety Investigation Branch. Wrong patient details on blood sample. 2024. Available from: https://www.hssib.org.uk/patient-safety-investigations/wrong-patient-details-on-blood-sample/investigation-report/
Serious Hazards of Transfusion. Annual SHOT Report. 2018.
Lippi G, Chance JJ, Church S, et al. Preanalytical quality improvement: from dream to reality. Clin Chem Lab Med. 2011;49(7):1113–26.
Lippi G, Plebani M. Hemolysis—not just an academic issue. Int J Lab Hematol. 2012;34(5):415–20.
Green SF. The cost of poor blood specimen quality and errors in preanalytical processes. Clin Biochem. 2013;46(13–14):1175–9.
Da Rin G. Pre-analytical workstations: A tool for reducing laboratory errors. Clin Chim Acta. 2015;446:20–8.
Kelly J, Cohen MB, Fine SW, et al. Mislabeling errors in pathology: a multisite study and system-based solution. Virchows Arch. 2023;482:345–353.
About the Author
Dr. Amar S. Bhogal is a junior doctor in the United Kingdom, dedicated to enhancing patient outcomes through the integration of advanced healthcare technologies. He has a robust background in medical research, having served as a Research Assistant at University College London's Institute for Liver and Digestive Health. His work has been pivotal in exploring the application of remote technology to support acute inpatient and transitional care, particularly for individuals with chronic obstructive pulmonary disease (COPD).
Beyond clinical medicine, Dr. Bhogal has held leadership roles in both the publishing and education sectors. He worked with Elsevier as a commissioning and managing editor for oncology journals, playing a key role in curating and advancing high-impact scientific research. Additionally, he served as a director for an educational startup focused on supporting children from disadvantaged backgrounds, demonstrating his commitment to widening access to education and fostering opportunities for young learners.
Passionate about the transformative potential of healthcare technologies, Dr. Bhogal is focused on leveraging innovative solutions to improve clinical practices and patient care.
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