@article{5384, keywords = {identification errors, labeling errors, quality measures, surgical pathology, surgical specimens}, author = {Paul J. Bixenstine and Richard J. Zarbo and Christine G. Holzmueller and Gayane Yenokyan and Raymond Robinson and Daniel W. Hudson and Arlene M. Prescott and Ron Hubble and Mary M. Murphy and Chris T. George and Rita D'Angelo and Sam Watson and Lisa H. Lubomski and Sean M. Berenholtz}, 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.

}, year = {2013}, journal = {Am J Med Qual}, volume = {28}, pages = {308-14}, month = {12/2013}, issn = {1555-824X}, doi = {10.1177/1062860612469824}, language = {eng}, }