"Once we solve a serious error, it improves our system and prevents other errors from happening," Dr. Hernandez said.

At UCSF, Dr. Hamill tracks all errors coming to his attention and compiles the data quarterly. Since the ED has had more mislabeling errors than other departments, he began collaboratively examining the department's processes and asking nurses questions, e.g., where they obtain labels, if the person who draws the samples also labels it, etc., to find points of failure.

"It's a constant process of monitoring, making some kind of intervention, then remonitoring," he said.

Buck Stop
The question of who is ultimately responsible for patient safety in the lab produces a range of answers.

The issue is black-and-white for Drs. Terrazas and Hamill. Everyone involved with a specimen is ultimately responsible for a patient's safety from the moment a specimen hits the lab's doorstep, Dr. Terrazas said.

And while Dr. Hamill agrees everyone in the lab is accountable for making lab testing and results as safe for the patient as possible, he said the person "ultimately responsible" is the name on the federal CLIA certificate--and in the state of California, the name on the state license, i.e., the medical director for the laboratory.

He said this is akin to saying President Obama is ultimately responsible for everything that happens in the U.S. government.

For Dr. Hernandez, the matter is less definitive. He said, "I laugh and say as laboratory medical director I'm the sheriff, but I deputize everybody in the laboratory to help me. Ultimately, if there's an unsafe environment in a laboratory, the buck stops with me. That's pretty clear from the Joint Commission and College of American Pathologists and CMS, but at the same time, I can't do this by myself. I need to make sure everybody is aware of safety and does their particular part."

Jill Hoffman is a on staff at ADVANCE.