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)

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

April 29, 2020

Managing the patient identification crisis in healthcare and laboratory medicine.

March 22, 2017

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

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

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

October 9, 2013

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

January 18, 2012

A nurse-led approach to developing and implementing a collaborative count policy.

February 22, 2012

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

July 27, 2022

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

October 30, 2013

Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study.

March 1, 2011

Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands.

October 1, 2008

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

High reliability leadership: a conceptual framework.

August 16, 2017

Clinical oversight: conceptualizing the relationship between supervision and safety.

July 25, 2007

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

April 20, 2016

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

March 14, 2007

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

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

January 4, 2006

Decision support and patient safety: the time has come.

January 19, 2011

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

November 13, 2019

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

September 20, 2023

Building bridges: future directions for medical error disclosure research.

July 24, 2013

Hospital complications: linking payment reduction to preventability.

May 6, 2009

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

Missed it.

March 27, 2013

Errors in nurse-led triage: an observational study.

December 2, 2020

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

December 12, 2018

Drug shortages: effect on parenteral nutrition therapy.

March 21, 2018

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

April 13, 2022

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

June 28, 2006

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

November 2, 2005

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

June 27, 2012

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

October 28, 2020

Why patients need leaders: introducing a ward safety checklist.

September 26, 2012

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

Using a medical emergency team to manage anaphylactic shock.

June 4, 2008

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

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

October 25, 2017

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

February 10, 2016

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

March 10, 2010

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

August 29, 2007

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

October 29, 2014

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

March 27, 2005

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

June 22, 2005

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

April 22, 2020

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

May 23, 2018

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

February 19, 2020

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

September 23, 2009

Toward a definition of teamwork in emergency medicine.

October 22, 2008

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

June 8, 2011

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

August 9, 2006

Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program.

April 30, 2014

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

August 18, 2021

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

June 30, 2021

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children.

June 30, 2021

Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis.

April 13, 2022

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

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

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

October 13, 2021

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

January 16, 2019

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

August 17, 2022

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

December 1, 2010

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

May 20, 2020

Challenging hierarchy in healthcare teams--ways to flatten gradients to improve teamwork and patient care.

April 19, 2017

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

January 25, 2012

Hospital Readmissions Reduction Program: implications for pharmacy.

February 18, 2015

Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents.

August 11, 2010

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

August 30, 2006

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

February 3, 2016

Exploring care left undone in pediatric nursing.

September 28, 2022

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

September 3, 2014

Addressing the health care needs of people who identify as transgender: what do nurses need to know?

July 22, 2020

Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements.

October 17, 2018

Teamwork and team performance in multidisciplinary cancer teams: development and evaluation of an observational assessment tool.

June 29, 2011

Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations.

May 5, 2010

Perceived patient safety culture in a critical care transport program.

July 31, 2013

A literature review of the individual and systems factors that contribute to medication errors in nursing practice.

September 16, 2009

Analysis of medication therapy discontinuation orders in new electronic prescriptions and opportunities for implementing CancelRx.

November 14, 2018

Quality and variability of patient directions in electronic prescriptions in the ambulatory care setting.

April 18, 2018

Boosting medical diagnostics by pooling independent judgments.

August 17, 2016

Critical Issues in Food Allergy: A National Academies Consensus Report.

September 6, 2017

Creating an integrated patient safety team.

August 10, 2005

Use of simulation to test systems and prepare staff for a new hospital transition.

September 19, 2018

Situational awareness—what it means for clinicians, its recognition and importance in patient safety.

August 24, 2016

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

August 31, 2016

Measuring psychological safety and local learning to enable high reliability organisational change.

November 9, 2022

An engineered solution to the maladministration of spinal injections.

January 13, 2010

The nature and occurrence of registration errors in the emergency department.

July 4, 2007

Smartphone distraction during nursing care: systematic literature review.

April 7, 2021

The work of nurses to provide good and safe services to children receiving hospital-at-home: a qualitative interview study from the perspectives of hospital nurses and physicians.

October 20, 2021

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

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

January 25, 2023

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

January 25, 2023

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

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

Systemic defenses to prevent intravenous medication errors in hospitals: a systematic review.

July 1, 2020

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

The wicked problem of patient misidentification: how could the technological revolution help address patient safety?

May 1, 2019

Evaluating the effect of data standardization and validation on patient matching accuracy.

April 10, 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

PSNet Log in

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