Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.

Giuseppe Lippi; Norbert Blanckaert; Pierangelo Bonini; Sol Green; Steve Kitchen; Vladimir Palicka; Anne J. Vassault; Camilla Mattiuzzi; Mario Plebani

Review

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.

April 22, 2009

Lippi G, Blanckaert N, Bonini P, et al. Clin Chem Lab Med. 2009;47(2):143-53.

View more articles from the same authors.

This review provides an overview of identification errors in laboratory medicine, building on past efforts to highlight practical solutions for prevention.

PubMed citation

Available at

Related Resources From the Same Author(s)

Managing the patient identification crisis in healthcare and laboratory medicine.

March 22, 2017

Potential preanalytical and analytical vulnerabilities in the laboratory diagnosis of coronavirus disease 2019 (COVID-19).

April 29, 2020

January 9, 2019

Towards a new paradigm in laboratory medicine: the five rights.

December 21, 2016

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

September 12, 2012

Errors in a stat laboratory: changes in type and frequency since 1996.

June 13, 2007

The cost of poor blood specimen quality and errors in preanalytical processes.

October 9, 2013

Identifying risk in the use of tumor markers to improve patient safety.

May 4, 2016

Patient identification and tube labelling—a call for harmonisation.

August 10, 2016

From COVID-19 pandemic to patient safety: a new "spring" for telemedicine or a boomerang effect?

July 27, 2022

Identifying barriers and enablers for a robust independent second check of medication in adult intensive care.

November 8, 2023

Adverse events experienced by homecare patients: a scoping review of the literature.

March 10, 2010

Developing a quality and safety curriculum for fellows: lessons learned from a neonatology fellowship program.

October 30, 2013

High reliability leadership: a conceptual framework.

August 16, 2017

Interventions to reduce the incidence of medical error and its financial burden in health care systems: a systematic review of systematic reviews.

August 31, 2022

Missed it.

March 27, 2013

Prescription errors in psychiatry - a multi-centre study.

September 6, 2006

An observational study of medication administration errors in old-age psychiatric inpatients.

July 4, 2007

Clinical oversight: conceptualizing the relationship between supervision and safety.

July 25, 2007

Toward a definition of teamwork in emergency medicine.

October 22, 2008

A review of medication administration errors reported in a large psychiatric hospital in the United Kingdom.

January 4, 2006

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

March 14, 2007

Decision support and patient safety: the time has come.

January 19, 2011

Improving patient safety through simulation training in anesthesiology: where are we?

April 20, 2016

Development and evaluation of a checklist to support decision making in cancer multidisciplinary team meetings: MDT-QuIC.

January 25, 2012

Under-mined.

January 17, 2007

Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences.

November 13, 2019

Perceived patient safety culture in a critical care transport program.

July 31, 2013

When illegitimate tasks threaten patient safety culture: a cross-sectional survey in a tertiary hospital.

October 11, 2023

Building bridges: future directions for medical error disclosure research.

July 24, 2013

Hospital complications: linking payment reduction to preventability.

May 6, 2009

Transfers of patient care between house staff on internal medicine wards: a national survey.

August 30, 2006

Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services.

November 19, 2014

Medication errors and drug-dispensing systems in a hospital pharmacy.

September 21, 2005

Regret among primary care physicians: a survey of diagnostic decisions.

April 15, 2020

The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program.

April 13, 2022

Drug shortages: effect on parenteral nutrition therapy.

March 21, 2018

Failure mode and effect analysis: a technique to prevent chemotherapy errors.

June 28, 2006

The Safer Delivery of Surgical Services Program (S3): explaining its differential effectiveness and exploring implications for improving quality in complex systems.

February 24, 2016

Factors associated with neuroradiologic diagnostic errors at a large tertiary-care academic medical center: a case-control study.

September 20, 2023

Closing the loop: follow-up and feedback in a patient safety program.

November 2, 2005

Interventions and measurements of highly reliable/resilient organization implementations: a literature review.

October 28, 2020

Burnout in mental health professionals: a systematic review and meta-analysis of prevalence and determinants.

December 12, 2018

Why patients need leaders: introducing a ward safety checklist.

September 26, 2012

Using a medical emergency team to manage anaphylactic shock.

June 4, 2008

A patient safety curriculum for graduate medical education: results from a needs assessment of educators and patient safety experts.

April 29, 2009

Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital.

August 19, 2009

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting.

May 17, 2017

Patient Safety Leadership WalkRounds.

March 6, 2005

Improving surgical complications and patient safety at the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data.

March 29, 2017

Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors.

October 27, 2021

Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.

August 7, 2013

Leading article: how can I optimise my role as a leader within the surgical team?

August 31, 2016

John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center.

March 27, 2005

Hospital deaths in patients with sepsis from 2 independent cohorts.

June 4, 2014

The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey.

June 27, 2012

Errors in nurse-led triage: an observational study.

December 2, 2020

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.

June 8, 2022

Incorporating nursing complexity in reimbursement coding systems: the potential impact on missed care.

October 25, 2017

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.

August 20, 2014

Framework for patient safety—part 1 and part 2.

November 9, 2011

Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act.

June 28, 2006

Necessity for a pathway for "high-alert" patients.

May 23, 2018

The road to zero preventable birth injuries.

April 9, 2008

Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study.

September 3, 2014

Application of a human factors classification framework for patient safety to identify precursor and contributing factors to adverse clinical incidents in hospital.

March 16, 2016

Use of a human factors classification framework to identify causal factors for medication and medical device-related adverse clinical incidents.

October 21, 2015

Emergency department communication links and patterns.

January 30, 2008

Development and implementation of an oral sign-out skills curriculum.

August 29, 2007

Human factors—recognising and minimising errors in our day to day practice.

February 10, 2016

Assessing distractors and teamwork during surgery: developing an event-based method for direct observation.

October 29, 2014

Health care quality and safety in a correctional system: creating goals and performance measures for improvement.

August 17, 2022

The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis.

October 13, 2021

Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system.

August 9, 2006

Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.

June 8, 2011

A preliminary taxonomy of medical errors in family practice.

March 6, 2005

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

March 6, 2005

Implementation of a comprehensive unit-based safety program to reduce surgical site infections in cesarean delivery.

April 22, 2020

Prospective daily review of discharge medications by pharmacists: effects on measures of safety and efficiency.

January 16, 2019

Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis.

May 20, 2020

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit.

December 1, 2010

Patients count on it: an initiative to reduce incorrect counts and prevent retained surgical items.

January 18, 2012

Misdiagnosis and missed diagnoses in foster and adopted children with prenatal alcohol exposure.

January 28, 2015

Psychological safety and infection prevention practices: results from a national survey.

February 19, 2020

Factors predictive of intravenous fluid administration errors in Australian surgical care wards.

June 22, 2005

Increasing demands for quality measurement.

November 27, 2013

Repeat medication errors in nursing homes: contributing factors and their association with patient harm.

July 28, 2010

"Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams.

February 19, 2020

The perceptions of nurses towards barriers to the safe administration of medicines in mental health settings.

February 3, 2016

Telemedicine as a medical examination tool during the Covid-19 emergency: the experience of the onco-haematology center of Tor Vergata Hospital in Rome.

December 23, 2020

Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation.

October 26, 2022

Intercepting wrong-patient orders in a computerized provider order entry system.

February 4, 2015

Assessment of patient-preferred language to achieve goal-aligned deprescribing in older adults.

June 30, 2021

The Child Health PSO at 10 years: an emerging learning network.

August 18, 2021

Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.

October 11, 2023

Anticoagulation patient safety goal compliance at a university health system: methods for achieving the goal.

September 23, 2009

Clinical dilemmas and a review of strategies to manage drug shortages.

May 15, 2013

Boosting medical diagnostics by pooling independent judgments.

August 17, 2016

Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU.

April 1, 2020

Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two 'early adopter' hospitals.

February 19, 2014

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Electronic health record use issues and diagnostic error: a scoping review and framework.

January 25, 2023

Assessment of the use of patient vital sign data for preventing misidentification and medical errors.

January 25, 2023

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

June 29, 2022

Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition to uptime.

April 27, 2022

Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative study.

November 17, 2021

Why and how to approach user experience in safety-critical domains: the example of health care.

September 8, 2021

A qualitative study of what care workers do to provide patient safety at home through telecare.

June 23, 2021

Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

June 23, 2021

Machine learning is booming in medicine. It’s also facing a credibility crisis.

June 16, 2021

What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study.

May 26, 2021

The potential of artificial intelligence to improve patient safety: a scoping review.

March 31, 2021

Impact of alarm fatigue on the work of nurses in an intensive care environment--a systematic review.

February 3, 2021

WebM&M Cases

Right Electrocardiogram, Wrong Patient

March 25, 2020

Algorithm based smartphone apps to assess risk of skin cancer in adults: systematic review of diagnostic accuracy studies.

March 3, 2020

WebM&M Cases

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

January 29, 2020

The use of patient digital facial images to confirm patient identity in a children's hospital's anesthesia information management system.

January 15, 2020

Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis.

December 18, 2019

Prevalence and predictability of low-yield inpatient laboratory diagnostic tests.

September 25, 2019

Patient Safety Primers

Patient Safety 101

September 7, 2019

Controversies in diagnosis: contemporary debates in the diagnostic safety literature.

July 17, 2019

Health Professions Education.

June 12, 2019

Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level.

May 29, 2019

Patients as diagnostic collaborators: sharing visit notes to promote accuracy and safety.

May 22, 2019

Virtual patients designed for training against medical error: exploring the impact of decision-making on learner motivation.

May 15, 2019

Governing the safety of artificial intelligence in healthcare.

May 8, 2019

See More About The Topic

Health Care Providers

Facility and Group Administrators

Information Professionals

Pathology and Laboratory Medicine

Diagnostic Errors

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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