A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.

Dawn L. Francis; Shalini Prabhakar; Schuyler O. Sanderson

Study

A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.

May 20, 2009

Francis DL, Prabhakar S, Sanderson SO. Am J Gastroenterol. 2009;104(4):972-975.

View more articles from the same authors.

This study successfully reduced specimen-labeling errors by implementation of a paperless protocol using radiofrequency identification technology.

PubMed citation

Related Resources From the Same Author(s)

Interruptions in healthcare: theoretical views.

February 18, 2009

Cultures of caring: healthcare 'scandals', inquiries, and the remaking of accountabilities.

March 14, 2018

Power of saying ‘I Don’t Know’: psychological safety and participatory strategies for healthcare leaders.

March 13, 2024

Barriers to adverse event and error reporting in anesthesia.

August 24, 2011

Organizational factors that promote error reporting in healthcare: a scoping review.

September 14, 2022

Mindful workarounds in bar code medication administration.

June 8, 2022

Advanced auditory displays and head-mounted displays: advantages and disadvantages for monitoring by the distracted anesthesiologist.

June 25, 2008

Traditions of research into interruptions in healthcare: a conceptual review.

January 11, 2017

The stories clinicians tell: achieving high reliability and improving patient safety.

December 2, 2015

Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation.

May 15, 2013

Does increased schedule flexibility lead to change? A national survey of program directors on 2017 work hours requirements.

September 23, 2020

Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals.

November 2, 2016

Organisational failure: rethinking whistleblowing for tomorrow's doctors.

September 7, 2022

Two sides to every story: the Dual Perspectives Method for examining interruptions in healthcare.

April 19, 2017

Use of information technology in medication reconciliation: a scoping review.

May 5, 2010

Will human factors restore faith in the GMC?

April 17, 2019

Designing a critical care nurse–led rapid response team using only available resources: 6 years later.

July 9, 2014

Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes.

September 16, 2009

Medication reconciliation improvement utilizing process redesign and clinical decision support.

January 29, 2020

Detecting drug interactions using personal digital assistants in an out-patient clinic.

October 31, 2007

What kinds of insights do Safety-I and Safety-II approaches provide? A critical reflection on the use of SHERPA and FRAM in healthcare.

February 21, 2024

A cluster randomized clinical trial to improve prescribing patterns in ambulatory pediatrics.

June 13, 2007

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

September 15, 2010

Patient safety science in cardiothoracic surgery: an overview.

March 16, 2016

Perceptions of risk to patient safety in the pediatric ICU, a study of American pediatric intensivists.

April 17, 2013

Dynamics of dignity and safety: a discussion.

January 24, 2018

Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family.

June 1, 2022

Individual characteristics that promote or prevent psychological safety and error reporting in healthcare: a systematic review.

May 10, 2023

Interruptions and blood transfusion checks: lessons from the simulated operating room.

February 4, 2009

Nursing resources and patient outcomes in intensive care: a systematic review of the literature.

November 14, 2007

Patient safety: disclosure of medical errors and risk mitigation.

August 3, 2016

Patient safety and telephone medicine: some lessons from closed claim case review.

February 13, 2008

Adverse effects of computers during bedside rounds in a critical care unit.

August 1, 2018

Understanding and preventing vaccination errors.

May 31, 2023

Obstacles to research on the effects of interruptions in healthcare.

February 10, 2016

Neuroradiology diagnostic errors at a tertiary academic centre: effect of participation in tumour boards and physician experience.

August 17, 2022

Emergency intubation of children outside of the operating room.

February 26, 2020

Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial.

July 15, 2020

Effect on patient safety of a resident physician schedule without 24-hour shifts.

July 15, 2020

Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit.

December 16, 2009

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

November 12, 2008

Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.

September 17, 2014

Extended work shifts and neurobehavioral performance in resident-physicians.

March 10, 2021

Human performance breakdowns are rarely accidents: they are usually very poor choices with disastrous results.

March 6, 2005

Effect of distractions on operative performance and ability to multitask—a case for deliberate practice.

July 1, 2015

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

May 11, 2022

Predicting future staffing needs at teaching hospitals: use of an analytical program with multiple variables.

April 25, 2007

The perceived impact of duty hour restrictions on the residency environment: a survey of residency program directors.

June 14, 2006

A case of adverse drug reaction induced by dispensing error.

November 7, 2012

Non-intercepted dose errors in prescribing antineoplastic treatment: a prospective, comparative cohort study.

March 11, 2015

Work-hour restrictions as an ethical dilemma for residents.

May 3, 2006

Postdischarge adverse events among neonates admitted to the neonatal intensive care unit.

September 7, 2022

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).

June 26, 2019

Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: a mixed methods study.

December 2, 2015

Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system.

March 8, 2023

Systematic error and cognitive bias in obstetric ultrasound.

May 15, 2019

Effect of ACGME duty hours on attending physician teaching and satisfaction.

June 18, 2008

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

Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.

September 12, 2007

Crisis recovery in surgery: error management and problem solving in safety-critical situations.

September 14, 2022

Using stakeholder intervention refinement teams to develop approaches for real-time integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions.

November 15, 2023

Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: a pilot study.

August 15, 2012

Mistakes and disclosure.

April 23, 2008

Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem.

March 12, 2014

Providers' and patients' perspectives on diagnostic errors in the acute care setting.

February 15, 2023

Simulation-based clinical rehearsals as a method for improving patient safety.

October 31, 2018

Teaching medical error disclosure to residents using patient-centered simulation training.

January 8, 2014

Availability of Spanish prescription labels.

March 1, 2006

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

April 30, 2008

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

February 27, 2008

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

August 24, 2005

A controlled trial of smart infusion pumps to improve medication safety in critically ill patients.

April 21, 2005

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization.

August 21, 2013

Perceptions of hospital safety climate and incidence of readmission.

December 15, 2010

Educational opportunities with postevent debriefing.

May 11, 2016

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

January 31, 2018

Retained lumbar catheter tip.

April 5, 2017

Surgical complications and their implications for surgeons' well-being.

January 22, 2014

Debriefing in the emergency department after clinical events: a practical guide.

December 17, 2014

To err is human, but what happens when surgeons err?

September 28, 2022

Improving resident handoffs for children transitioning from the intensive care unit.

April 8, 2015

Predictors of treatment error for children with uncomplicated malaria seen as outpatients in Blantyre district, Malawi.

September 13, 2006

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

August 10, 2011

Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry.

July 19, 2006

Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications.

November 13, 2013

Patient safety informatics: meeting the challenges of emerging digital health.

July 20, 2022

Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention.

November 29, 2023

How to improve the delivery of medication alerts within computerized physician order entry systems: an international Delphi study.

July 13, 2011

Digital health and patient safety.

April 27, 2016

Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting.

June 3, 2015

Field test of the World Health Organization Multi-professional Patient Safety Curriculum Guide.

October 14, 2015

Safety of medication use in primary care.

March 4, 2015

Dementia and risk of adverse warfarin-related events in the nursing home setting.

November 21, 2012

Project BOOST implementation: lessons learned.

September 10, 2014

Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings.

July 12, 2017

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

October 2, 2013

Introducing new technology into the operating room: measuring the impact on job performance and satisfaction.

June 8, 2005

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

February 23, 2011

Association of communication between hospital-based physicians and primary care providers with patient outcomes.

January 21, 2009

Related Resources

Patient Safety Authority Annual Reports.

May 1, 2023

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

March 22, 2023

Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

February 8, 2023

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

WebM&M Cases

Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.

October 27, 2022

Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events.

September 28, 2022

Perspective

The Media’s Role in Patient Safety

April 27, 2022

WebM&M Cases

Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room

April 27, 2022

Technology-based closed-loop tracking for improving communication and follow-up of pathology results.

February 2, 2022

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

September 29, 2021

Exploring the association between organizational safety climate, failure to rescue, and mortality in inpatient surgical units.

February 3, 2021

Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities.

January 20, 2021

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

September 23, 2020

What constitutes effective team communication after an error?

May 27, 2020

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

Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019

December 4, 2019

Electronic patient identification for sample labeling reduces wrong blood in tube errors.

March 20, 2019

Implementation of bar-code medication administration to reduce patient harm.

February 20, 2019

Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

February 13, 2019

Perioperative medication errors: uncovering risk from behind the drapes.

January 16, 2019

Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

January 9, 2019

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.

November 21, 2018

Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals.

April 25, 2018

Safety with nebulized medications requires an interdisciplinary team approach.

March 7, 2018

Errors detected in pediatric oral liquid medication doses prepared in an automated workflow management system.

February 28, 2018

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors.

August 16, 2017

Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.

February 15, 2017

Comparison of medication safety systems in critical access hospitals: combined analysis of two studies.

September 21, 2016

See More About The Topic

Outpatient Surgery

Health Care Providers

Quality and Safety Professionals

Information Professionals

General Surgery

A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.

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