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

Raouf E. Nakhleh; Michael O. Idowu; Rhona J. Souers; Frederick A. Meier; Leonas G. Bekeris

Study

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

September 14, 2011

Nakhleh RE, Idowu MO, Souers RJ, et al. Arch Pathol Lab Med. 2011;135(8):969-74.

View more articles from the same authors.

Looking across 136 institutions, this study quantified mislabeling rates at a cumulative total of 0.11% for cases, specimens, blocks, and slides. The authors reinforce the need for quality monitoring since most errors were caught in the immediate steps following the error.

PubMed citation

Available at

Related Resources From the Same Author(s)

Patient safety and error reduction in surgical pathology.

February 20, 2008

Patient safety in anatomic pathology: measuring discrepancy frequencies and causes.

April 15, 2005

Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.

June 17, 2015

Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors.

February 8, 2006

Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories.

November 12, 2008

Recommendations for quality assurance and improvement in surgical and autopsy pathology.

August 9, 2006

Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.

June 7, 2017

Clinical impact and frequency of anatomic pathology errors in cancer diagnoses.

October 26, 2005

Anatomic pathology databases and patient safety.

October 19, 2005

Errors in thyroid gland fine-needle aspiration.

May 31, 2006

Frequency and outcome of cervical cancer prevention failures in the United States.

December 19, 2007

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

July 19, 2006

Patient safety in surgery: non-technical aspects of safe surgical performance.

April 7, 2010

Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.

January 10, 2007

Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.

October 26, 2011

Patterns of communication breakdowns resulting in injury to surgical patients.

April 11, 2007

Communicating doses of pediatric liquid medicines to parents/caregivers: a comparison of written dosing directions on prescriptions with labels applied by dispensed pharmacy.

May 21, 2014

Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.

January 18, 2006

Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study.

February 27, 2008

Meaningful use of health information technology and declines in in-hospital adverse drug events.

March 8, 2017

Intraoperative patient information handover between anesthesia providers.

November 5, 2014

Rudeness at work.

July 21, 2010

Measuring safety culture in healthcare: a case for accurate diagnosis.

June 27, 2007

Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study.

November 8, 2006

Frequency of failure to inform patients of clinically significant outpatient test results.

June 24, 2009

Effects of shift length on quality of patient care and health provider outcomes: systematic review.

June 10, 2009

Impact of feeling responsible for adverse events on doctors' personal and professional lives: the importance of being open to criticism from colleagues.

July 25, 2007

Functional health literacy and understanding of medications at discharge.

July 16, 2008

Development and measurement of perioperative patient safety indicators.

March 18, 2015

Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals.

December 17, 2008

Review article: the influence of psychology and human factors on education in anesthesiology.

January 30, 2005

Senior charge nurses' leadership behaviours in relation to hospital ward safety: a mixed method study.

November 27, 2013

Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients.

July 1, 2009

Doctors' handovers in hospitals: a literature review.

March 2, 2011

The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical task analysis.

February 29, 2012

Improving measurement in clinical handover.

August 19, 2009

Surgeons' non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system.

March 5, 2008

Assessing and monitoring override medications in automated dispensing devices.

May 31, 2006

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.

May 4, 2005

An objective study of the impact of the electronic medical record on outcomes in trauma patients.

November 21, 2012

Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training.

May 16, 2018

A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families.

July 1, 2015

Use of specific indicators to detect warfarin-related adverse events.

August 24, 2005

Health care provider factors associated with patient-reported adverse events and harm.

May 20, 2020

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.

August 24, 2011

Systematic error and cognitive bias in obstetric ultrasound.

May 15, 2019

Variation in caregiver perceptions of teamwork climate in labor and delivery units.

July 5, 2006

Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents.

September 18, 2019

Studying critical values: adverse event identification following a critical laboratory values study at the Ohio State University Medical Center.

October 17, 2007

Incidence, nature and impact of error in surgery.

August 3, 2011

Errors as allies: error management training in health professions education.

January 23, 2013

The effects of safety checklists in medicine: a systematic review.

December 4, 2013

Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds.

May 29, 2019

Readiness of US general surgery residents for independent practice.

October 4, 2017

Causes of near misses in critical care of neonates and children.

April 30, 2008

Hospital safety climate surveys: measurement issues.

October 20, 2010

Learning from malpractice claims about negligent, adverse events in primary care in the United States.

March 6, 2005

Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events.

June 7, 2017

Role of registered nurses in error prevention, discovery and correction.

April 16, 2008

Iatrogenic harm caused by diagnostic errors in fibrodysplasia ossificans progressiva.

November 23, 2005

Implementing an obstetric emergency team response system: overcoming barriers and sustaining response dose.

November 4, 2015

Missed diagnoses by urologists resulting in malpractice payment.

October 31, 2007

Safety of overlapping inpatient orthopaedic surgery: a multicenter study.

January 16, 2019

Realizing e-prescribing's potential to reduce outpatient psychiatric medication errors.

January 31, 2018

A simulation design for research evaluating safety innovations in anaesthesia.

January 28, 2009

What can apologies in the electronic health record tell us about health care quality, processes, and safety?

August 29, 2018

The interplay between teamwork, clinicians' emotional exhaustion, and clinician-rated patient safety: a longitudinal study.

May 4, 2016

Emotional exhaustion and workload predict clinician-rated and objective patient safety.

April 1, 2015

Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.

January 21, 2015

A case of adverse drug reaction induced by dispensing error.

November 7, 2012

Adverse-event-reporting practices by US hospitals: results of a national survey.

January 7, 2009

Teamwork in healthcare: key discoveries enabling safer, high-quality care.

July 11, 2018

Finding dental harm to patients through electronic health record-based triggers.

February 19, 2020

Workplace factors associated with burnout of family physicians.

May 31, 2017

Prevalence of adverse events in the hospitals of five Latin American countries: results of the 'Iberoamerican Study of Adverse Events' (IBEAS).

August 10, 2011

Mistakes and disclosure.

April 23, 2008

Teamwork behaviours and errors during neonatal resuscitation.

March 24, 2010

Embedding quality and safety in otolaryngology–head and neck surgery education.

January 21, 2015

Reducing drug prescription errors and adverse drug events by application of a probabilistic, machine-learning based clinical decision support system in an inpatient setting.

August 21, 2019

The scope of drug-related problems in the home care setting.

July 25, 2018

Team communication during patient handover from the operating room: more than facts and figures.

April 24, 2013

How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis.

November 13, 2019

Communication skills and error in the intensive care unit.

November 28, 2007

The Armstrong Institute: an academic institute for patient safety and quality improvement, research, training, and practice.

June 10, 2015

Major congenital malformations after first-trimester exposure to ACE inhibitors.

June 21, 2006

Analysis of consistency in emergency department physician variation in propensity for admission across patient sociodemographic groups.

October 13, 2021

Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.

November 14, 2007

Can teaching medical students to investigate medication errors change their attitudes towards patient safety?

February 16, 2011

Preventing adverse events in cataract surgery: recommendations from a Massachusetts expert panel.

August 8, 2018

Differences in medication knowledge and risk of errors between graduating nursing students and working registered nurses: comparative study.

February 4, 2015

"Canary measures" among the AHRQ Patient Safety Indicators.

September 9, 2009

Multiple patient safety events within a single hospitalization: a national profile in US hospitals.

April 25, 2012

Relationship between patient safety climate and standard precaution adherence: a systematic review of the literature.

November 25, 2015

Incidence and types of preventable adverse events in elderly patients: population based review of medical records.

March 27, 2005

A preliminary taxonomy of medical errors in family practice.

March 6, 2005

Characteristics associated with requests by pathologists for second opinions on breast biopsies.

May 17, 2017

How much diagnostic safety can we afford, and how should we decide? A health economics perspective.

October 2, 2013

Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals.

January 11, 2023

Single-patient rooms for safe patient-centered hospitals.

September 10, 2008

The potential of Twitter as a data source for patient safety.

January 27, 2016

Related Resources

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Diagnostic stewardship to prevent diagnostic error.

March 15, 2023

Development and pilot evaluation of an electronic health record usability and safety self-assessment tool.

August 24, 2022

Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results.

June 29, 2022

Emergency departments are higher-risk locations for wrong blood in tube errors.

September 29, 2021

WebM&M Cases

Pre-analytical pitfalls: Missing and mislabeled specimens

February 26, 2020

WebM&M Cases

“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event

January 29, 2020

Patient Safety Primers

Patient Safety 101

September 7, 2019

Medication Safety in Key Action Areas.

July 10, 2019

Managing the patient identification crisis in healthcare and laboratory medicine.

March 22, 2017

Getting it right for patient safety: specimen collection process improvement from operating room to pathology.

September 28, 2016

Do work condition interventions affect quality and errors in primary care? Results from the Healthy Work Place Study.

September 28, 2016

Patient identification and tube labelling—a call for harmonisation.

August 10, 2016

The effect of contact precautions on frequency of hospital adverse events.

December 9, 2015

Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction.

November 11, 2015

Overreaction.

November 4, 2015

Use of quality indicators to compare point-of-care testing errors in a neonatal unit and errors in a STAT central laboratory.

February 25, 2015

Patient Safety Essentials for Laboratory Professionals Certificate Program.

December 10, 2014

Reducing emergency department charting and ordering errors with a room number watermark on the electronic medical record display.

December 10, 2014

Patient safety and quality care.

July 30, 2014

A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital.

July 9, 2014

"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

March 5, 2014

Confusion—specimen mix-up in dermatopathology and measures to prevent and detect it.

February 26, 2014

Improving Patient Safety in Laboratory Medicine.

October 9, 2013

When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine.

September 11, 2013

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.

August 21, 2013

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

March 27, 2013

Quality improvement: Universal Protocol use in office-based gastrointestinal procedure units.

January 9, 2013

Quality indicators to detect pre-analytical errors in laboratory testing.

September 12, 2012

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Pathology and Laboratory Medicine

Identification Errors

Epidemiology of Errors and Adverse Events

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

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site