AHRQ Patient Safety Network

The Collection > Identification Errors

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Identification Errors

•Wrong Patient (45)

•Wrong-Site Surgery (67)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (119)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (37)

•Special or Theme Issue (2)

•Tools/Toolkit (5)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (59)

•Active Errors (78)

•Latent Errors (20)

•Near Miss (13)

Approach to Improving Safety

•Quality Improvement Strategies (61)

•Legal and Policy Approaches (13)

•Error Reporting and Analysis (61)

•Communication Improvement (83)

•Human Factors Engineering (51)

•Teamwork (17)

•Specialization of Care (2)

•Logistical Approaches (24)

•Culture of Safety (15)

•Technologic Approaches (48)

•Education and Training (31)

Clinical Areas

Target Audience

•Health Care Providers (126)

•Health Care Executives and Administrators (138)

•Non-Health Care Professionals (44)

•Patients (36)

Setting of Care

•Hospitals (134)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (14)

•Outpatient Surgery (10)

1 - 20 of 189

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STUDY

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

STUDY

Surgical confusions in ophthalmology.

Simon JW, Ngo Y, Khan S, Strogatz D. Arch Ophthalmol. 2007;125:1515-1522.

STUDY

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

Wagar EA, Tamashiro L, Yasin B, Hilborne L, Bruckner DA. Arch Pathol Lab Med. 2006;130:1662-1668.

STUDY

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

NEWSPAPER/MAGAZINE ARTICLE

Surgical errors: new products, protocols help slash the risks.

Williamson JE. Healthcare Purchasing News. January 2006;30:22-25.

COMMENTARY classic

Errors in laboratory medicine: practical lessons to improve patient safety.

Howanitz PJ. Arch Pathol Lab Med. 2005;129:1252-1261.

STUDY

Perioperative patient safety: correct patient, correct surgery, correct side--a multifaceted, cross-organizational, interventional study.

Zohar E, Noga Y, Davidson E, Kantor M, Fredman B. Anesth Analg. 2007;105:443-447.

STUDY

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.

STUDY

Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions.

Valenstein PN, Raab SS, Walsh MK. Arch Pathol Lab Med. 2006;130:1106-1113.

STUDY

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Am J Med Qual. 2013 Jan 15; [Epub ahead of print].

NEWSLETTER/JOURNAL

Laboratory Errors & Patient Safety.

Seattle, WA: Medical Training Solutions.

STUDY

Mislabeling of cases, specimens, blocks, and slides: a College of American Pathologists study of 136 institutions.

Nakhleh RE, Idowu MO, Souers RJ, Meier FA, Bekeris LG. Arch Pathol Lab Med. 2011;135:969-974.

STUDY

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

STUDY

Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital.

Hayden RT, Patterson DJ, Jay DW, et al. J Pediatr. 2008;152:219-224.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

REVIEW

Identifying cross contaminants and specimen mix-ups in surgical pathology.

Hunt JL. Adv Anat Pathol. 2008;15:211-217.

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