A reported adverse event at the Policlinico Umberto I in Rome, Italy, in which a healthy 35-year-old man underwent partial mandibulectomy after an alleged biopsy transposition with another patient diagnosed with high-grade osteosarcoma, represents a sentinel example of specimen chain-of-custody failure in oral and maxillofacial surgery.
This case-based narrative review distinguishes clinical diagnostic reasoning in mandibular oncology from pre-analytic and analytic failures in specimen identification, using the publicly reported Rome case as an educational anchor for prevention.
The reported chronology was reconstructed from open journalistic sources and interpreted in light of the literature on surgical pathology specimen misidentification, wrong-patient procedures, DNA-based specimen provenance testing, disclosure after adverse events, and second-victim support.
The case shows key features of specimen-identity failures: late detection, possible reproduction of the error during slide-based second opinion, poor visibility to routine laboratory quality control, and simultaneous harm to at least two patients. Unlike cognitive diagnostic errors, specimen transpositions cannot be corrected by expert reinterpretation of the same misattributed material.
Clinical excellence alone cannot prevent harm when tissue is attributed to the wrong patient. A phase-specific framework incorporating disciplined labeling, structured handover, pathology identity checks, pre-resection diagnostic time-out, DNA-based provenance testing, transparent disclosure, and psychological support may reduce the risk and impact of similar events.
Citation: Luca Fiorillo. Distinguishing clinical diagnosis from specimen chain-of-custody failures in oral and maxillofacial surgery: A case-based analysis of the Rome mandibulectomy and a framework for system-level prevention[J]. Journal of Dentistry and Multidisciplinary Sciences, 2026, 2(1): 39-51. doi: 10.3934/jdms.2026006
A reported adverse event at the Policlinico Umberto I in Rome, Italy, in which a healthy 35-year-old man underwent partial mandibulectomy after an alleged biopsy transposition with another patient diagnosed with high-grade osteosarcoma, represents a sentinel example of specimen chain-of-custody failure in oral and maxillofacial surgery.
This case-based narrative review distinguishes clinical diagnostic reasoning in mandibular oncology from pre-analytic and analytic failures in specimen identification, using the publicly reported Rome case as an educational anchor for prevention.
The reported chronology was reconstructed from open journalistic sources and interpreted in light of the literature on surgical pathology specimen misidentification, wrong-patient procedures, DNA-based specimen provenance testing, disclosure after adverse events, and second-victim support.
The case shows key features of specimen-identity failures: late detection, possible reproduction of the error during slide-based second opinion, poor visibility to routine laboratory quality control, and simultaneous harm to at least two patients. Unlike cognitive diagnostic errors, specimen transpositions cannot be corrected by expert reinterpretation of the same misattributed material.
Clinical excellence alone cannot prevent harm when tissue is attributed to the wrong patient. A phase-specific framework incorporating disciplined labeling, structured handover, pathology identity checks, pre-resection diagnostic time-out, DNA-based provenance testing, transparent disclosure, and psychological support may reduce the risk and impact of similar events.
| [1] | L. T. Kohn, J. M. Corrigan, M. S. Donaldson, To Err Is Human: Building a Safer Health System, National Academies Press, Washington, DC, 2000. |
| [2] |
S. Laskar, A. Basu, M. A. Muckaden, A. D'Cruz, S. Pai, N. Jambhekar, et al., Osteosarcoma of the head and neck region: lessons learned from a single-institution experience of 50 patients, Head Neck, 30 (2008), 1020–1026.https://doi.org/10.1002/hed.20820 doi: 10.1002/hed.20820
|
| [3] |
M. K. Rajab, B. I. Awad, H. A. Al-Hakami, H. Al-Maghrabi, Diagnostic challenges in chondroblastic maxillary osteosarcoma: A case report, Cureus, 12 (2020), e8418.https://doi.org/10.7759/cureus.8418 doi: 10.7759/cureus.8418
|
| [4] |
Y. M. Chen, Q. C. Shen, S. Gokavarapu, H. S. Ong, W. Cao, T. Ji, Osteosarcoma of the mandible: A site-specific study on survival and prognostic factors, J. Craniofac. Surg., 27 (2016), 1929–1933.https://doi.org/10.1097/SCS.0000000000002968 doi: 10.1097/SCS.0000000000002968
|
| [5] | R. E. Nakhleh, R. J. Zarbo, Surgical pathology specimen identification and accessioning: A College of American Pathologists Q-Probes study of 1,004,115 cases from 417 institutions, Arch. Pathol. Lab. Med., 120 (1996), 227–233. |
| [6] |
R. E. Nakhleh, M. O. Idowu, R. J. Souers, F. A. Meier, L. G. Bekeris, Mislabeling of cases, specimens, blocks, and slides: A College of American Pathologists study of 136 institutions, Arch. Pathol. Lab. Med., 135 (2011), 969–974.https://doi.org/10.5858/2010-0726-CPR doi: 10.5858/2010-0726-CPR
|
| [7] |
P. N. Valenstein, S. S. Raab, M. K. Walsh, Identification errors involving clinical laboratories: A College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions, Arch. Pathol. Lab. Med., 130 (2006), 1106–1113.https://doi.org/10.5858/2006-130-1106-IEICL doi: 10.5858/2006-130-1106-IEICL
|
| [8] |
M. A. Makary, J. Epstein, P. J. Pronovost, E. A. Millman, E. C. Hartmann, J. A. Freischlag, Surgical specimen identification errors: A new measure of quality in surgical care, Surgery, 141 (2007), 450–455.https://doi.org/10.1016/j.surg.2006.08.018 doi: 10.1016/j.surg.2006.08.018
|
| [9] |
J. D. Pfeifer, J. Liu, Rate of occult specimen provenance complications in routine clinical practice, Am. J. Clin. Pathol., 139 (2013), 93–100.https://doi.org/10.1309/AJCP50WEZHWIFCIV doi: 10.1309/AJCP50WEZHWIFCIV
|
| [10] |
P. N. Valenstein, R. L. Sirota, Identification errors in pathology and laboratory medicine, Clin. Lab. Med., 24 (2004), 979–996.https://doi.org/10.1016/j.cll.2004.05.013 doi: 10.1016/j.cll.2004.05.013
|
| [11] |
E. J. Suba, J. D. Pfeifer, S. S. Raab, Patient identification error among prostate needle core biopsy specimens: Are we ready for a DNA time-out, J. Urol., 178 (2007), 1245–1248.https://doi.org/10.1016/j.juro.2007.05.152 doi: 10.1016/j.juro.2007.05.152
|
| [12] |
L. J. Layfield, G. M. Anderson, Specimen labeling errors in surgical pathology: An 18-month experience, Am. J. Clin. Pathol., 134 (2010), 466–470.https://doi.org/10.1309/AJCPHLQHJ0S3DFJK doi: 10.1309/AJCPHLQHJ0S3DFJK
|
| [13] |
J. D. Pfeifer, B. Zehnbauer, J. Payton, The changing spectrum of DNA-based specimen provenance testing in surgical pathology, Am. J. Clin. Pathol., 135 (2011), 132–138.https://doi.org/10.1309/AJCPLNO4PFVZVA4P doi: 10.1309/AJCPLNO4PFVZVA4P
|
| [14] |
P. A. Brennan, M. T. Brands, L. Caldwell, F. P. Fonseca, N. Turley, S. Foley, et al., Surgical specimen handover from the operating theatre to laboratory: Can we improve patient safety by learning from aviation and other high-risk organisations, J. Oral Pathol. Med., 47 (2018), 117–120.https://doi.org/10.1111/jop.12614 doi: 10.1111/jop.12614
|
| [15] |
M. R. Kwaan, D. M. Studdert, M. J. Zinner, A. A. Gawande, Incidence, patterns, and prevention of wrong-site surgery, Arch. Surg., 141 (2006), 353–357.https://doi.org/10.1001/archsurg.141.4.353 doi: 10.1001/archsurg.141.4.353
|
| [16] |
M. R. Mariappan, J. Zehnder, D. A. Arber, M. Lay, O. Fadare, I. Schrijver, Identification of mislabeled specimen by molecular methods: Case report and review, Int. J. Surg. Pathol., 13 (2005), 253–258.https://doi.org/10.1177/106689690501300304 doi: 10.1177/106689690501300304
|
| [17] |
C. A. Vincent, A. Coulter, Patient safety: What about the patient, Qual. Saf. Health Care, 11 (2002), 76–80.https://doi.org/10.1136/qhc.11.1.76 doi: 10.1136/qhc.11.1.76
|
| [18] |
S. D. Scott, L. E. Hirschinger, K. R. Cox, M. McCoig, J. Brandt, L. W. Hall, The natural history of recovery for the healthcare provider "second victim" after adverse patient events, Qual. Saf. Health Care, 18 (2009), 325–330.https://doi.org/10.1136/qshc.2009.032870 doi: 10.1136/qshc.2009.032870
|
| [19] |
A. D. Waterman, J. Garbutt, E. Hazel, W. C. Dunagan, W. Levinson, V. J. Fraser, et al., The emotional impact of medical errors on practicing physicians in the United States and Canada, Jt. Comm. J. Qual. Patient Saf., 33 (2007), 467–476.https://doi.org/10.1016/S1553-7250(07)33050-X doi: 10.1016/S1553-7250(07)33050-X
|
| [20] |
J. Reason, Human error: Models and management, BMJ, 320 (2000), 768–770.https://doi.org/10.1136/bmj.320.7237.768 doi: 10.1136/bmj.320.7237.768
|
| [21] |
A. B. Haynes, T. G. Weiser, W. R. Berry, S. R. Lipsitz, A. H. S. Breizat, E. P. Dellinger, et al., A surgical safety checklist to reduce morbidity and mortality in a global population, N. Engl. J. Med., 360 (2009), 491–499.https://doi.org/10.1056/NEJMsa0810119 doi: 10.1056/NEJMsa0810119
|
| [22] | W. R. Martis, J. A. Hannam, T. Lee, A. F. Merry, S. J. Mitchell, Improved compliance with the World Health Organization Surgical Safety Checklist is associated with reduced surgical specimen labelling errors, N. Z. Med. J., 129 (2016), 63–67. |
| [23] |
V. M. Steelman, T. L. Williams, M. K. Szekendi, A. L. Halverson, S. M. Dintzis, S. Pavkovic, Surgical specimen management: A descriptive study of 648 adverse events and near misses, Arch. Pathol. Lab. Med. , 140 (2016), 1390–1396.https://doi.org/10.5858/arpa.2016-0021-OA doi: 10.5858/arpa.2016-0021-OA
|
Luca Fiorillo. Distinguishing clinical diagnosis from specimen chain-of-custody failures in oral and maxillofacial surgery: A case-based analysis of the Rome mandibulectomy and a framework for system-level prevention[J]. Journal of Dentistry and Multidisciplinary Sciences, 2026, 2(1): 39-51. doi: 10.3934/jdms.2026006
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