title: Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.
abstract: Accurate patient identification is a National Patient Safety Goal. Misidentification of surgical specimens is associated with increased morbidity, mortality, and costs of care. The authors developed 12 practical, process-based, standardized measures of surgical specimen identification defects during the preanalytic phase of pathology testing (from the operating room to the surgical pathology laboratory) that could be used to quantify the occurrence of these defects. The measures (6 container and 6 requisition identification defects) were developed by a panel of physicians, pathologists, nurses, and quality experts. A total of 69 hospitals prospectively collected data over 3 months. Overall, there were identification defects in 2.9% of cases (1780/60 501; 95% confidence interval [CI] = 2.0%-4.4%), 1.2% of containers (1018/81 656; 95% CI = 0.8%-2.0%), and 2.3% of requisitions (1417/61 245; 95% CI = 1.2%-4.6%). Future research is needed to evaluate if hospitals are able to use these measures to assess interventions meant to reduce the frequency of specimen identification defects and improve patient safety.
authors: The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
authors: Paul J
authors: PJ
authors: Bixenstine
authors: Richard J
authors: RJ
authors: Zarbo
authors: Christine G
authors: CG
authors: Holzmueller
authors: Gayane
authors: G
authors: Yenokyan
authors: Raymond
authors: R
authors: Robinson
authors: Daniel W
authors: DW
authors: Hudson
authors: Arlene M
authors: AM
authors: Prescott
authors: Ron
authors: R
authors: Hubble
authors: Mary M
authors: MM
authors: Murphy
authors: Chris T
authors: CT
authors: George
authors: Rita
authors: R
authors: D'Angelo
authors: Sam R
authors: SR
authors: Watson
authors: Lisa H
authors: LH
authors: Lubomski
authors: Sean M
authors: SM
authors: Berenholtz
mesh_terms: D006801:Humans; D007484:Iowa; D008824:Michigan; D010340:Pathology, Surgical; D010355:Patient Identification Systems / Q000592:standards*; D061214:Patient Safety; D010865:Pilot Projects; D016730:Program Development; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D013048:Specimen Handling
keywords: identification errors; labeling errors; quality measures; surgical pathology; surgical specimens