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Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.
February 17, 2010
Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134(2):244-255.
Data from root cause analyses were used to identify causal factors for patient misidentification errors in clinical laboratories, pathology, and the blood bank. 253 adverse events were found, 182 of which were patient misidentification. Errors occurred in all three states of the test cycle.
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