Reducing specimen identification errors.

Susan Rees; Linda Stevens; Diane Mikelsons; Elsa Quam; Teresa Darcy

Commentary

Reducing specimen identification errors.

April 11, 2012

Rees S, Stevens L, Mikelsons D, et al. J Nurs Care Qual. 2012;27(3):253-7.

View more articles from the same authors.

This commentary describes a hospital safety improvement effort based on just culture principles that reduced specimen identification errors.

PubMed citation

Available at

Related Resources From the Same Author(s)

The relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan Canadian study.

October 2, 2013

The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors.

April 27, 2016

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: a systematic review of randomized trials and non-randomized intervention studies.

August 18, 2021

Implementing standardized reporting and safety checklists.

June 1, 2011

Iatrogenic psychological harm.

November 30, 2011

Introduction of discharge plan to reduce adverse events within 72 hours of discharge from the ICU.

August 12, 2009

2008 Annual National Patient Safety Foundation Congress: conference proceedings.

September 24, 2008

Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports.

April 1, 2020

Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis.

February 1, 2017

Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety.

November 29, 2017

Resident to resident handoffs in the emergency department: an observational study.

October 22, 2014

Safety incidents in the primary care office setting.

May 20, 2015

Harms from discharge to primary care: mixed methods analysis of incident reports.

December 16, 2015

On the ball: leadership for patient safety and learning in critical care.

August 12, 2009

How to develop a second victim support program: a toolkit for health care organizations.

May 2, 2012

Improving perceptions of patient safety through standardizing handoffs from the emergency department to the inpatient setting: a systematic review.

August 7, 2019

Understanding the healthcare workplace learning culture through safety and dignity narratives: a UK qualitative study of multiple stakeholders' perspectives.

June 12, 2019

Nursing strategies to safeguard COVID-19 patients from harm in the intensive care unit.

December 8, 2021

Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules.

March 23, 2011

Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education.

January 19, 2011

'Even now it makes me angry': health care students' professionalism dilemma narratives.

August 6, 2014

Learning not to take it seriously: junior doctors' accounts of error.

October 15, 2008

Improving patient safety by repeating (read-back) telephone reports of critical information.

March 6, 2005

Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative.

October 5, 2022

How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England.

August 23, 2017

Communication between primary and secondary care: deficits and danger.

August 21, 2019

Patient safety culture as a space of social struggle: understanding infection prevention practice and patient safety culture within hospital isolation settings - a qualitative study.

December 14, 2022

A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population.

April 10, 2019

Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis.

October 24, 2018

Safety culture, patient safety, and quality of care outcomes: a literature review.

January 31, 2018

The impact of adverse events on clinicians: what's in a name?

November 22, 2017

The combined effect of psychological and social capital in registered nurses experiencing second victimization: a structural equation model.

December 1, 2021

Associations between attending physician workload, teaching effectiveness, and patient safety.

February 3, 2016

Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service.

November 21, 2018

Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study.

August 30, 2023

Failure mode and effects analysis to reduce risk of heparin use.

January 29, 2020

Towards high-reliability organising in healthcare: a strategy for building organisational capacity.

June 7, 2017

The technologist's role in patient safety and quality in medical imaging.

June 5, 2013

A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative.

October 17, 2012

Hospital nurse staffing and patient mortality, emotional exhaustion, and job dissatisfaction.

October 26, 2005

When doing wrong feels so right: normalization of deviance.

March 25, 2015

Maintaining maternal-newborn safety during the COVID-19 pandemic.

May 26, 2021

Considerations for the design of safe and effective consumer health IT applications in the home.

November 17, 2010

Teaching nurses to make clinical judgments that ensure patient safety.

August 14, 2019

Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care.

June 28, 2017

Types, prevalence, and potential clinical significance of medication administration errors in assisted living.

June 4, 2008

Associations between in-hospital mortality, health care utilization, and inpatient costs with the 2011 resident duty hour revision.

May 15, 2019

The impact of power on health care team performance and patient safety: a review of the literature.

April 21, 2021

Building safer systems through critical occurrence reviews: nine years of learning.

November 10, 2010

The human factors of home health care: a conceptual model for examining safety and quality concerns.

December 9, 2009

Prescription for error: process defects in a community retail pharmacy.

December 19, 2007

Hospital infection prevention: how much can we prevent and how hard should we try?

March 6, 2019

Serious incidents after death: content analysis of incidents reported to a national database.

May 16, 2018

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice.

October 12, 2016

Impact of duty hour regulations on medical students' education: views of key clinical faculty.

July 23, 2008

Promoting patient safety: results of a TeamSTEPPS initiative.

May 11, 2016

Incidence and variables associated with inconsistencies in opioid prescribing at hospital discharge and its associated adverse drug outcomes.

May 5, 2021

Mitigating patient and consumer safety risks when using conversational assistants for medical information: exploratory mixed methods experiment.

December 15, 2021

Discrepancies between home medications listed at hospital admission and reported medical conditions.

October 22, 2008

Identifying the 'right patient': nurse and consumer perspectives on verifying patient identity during medication administration.

May 11, 2011

Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments.

May 9, 2007

Standardized assessment of medication reconciliation in post-acute care.

April 27, 2022

Promoting civility in the OR: an ethical imperative.

March 8, 2017

Patient safety: break the silence.

May 9, 2012

A clinical nurse specialist intervention to facilitate safe transfer from ICU.

November 30, 2011

Leading your organization to high reliability.

April 22, 2009

Different roles, same goal: risk and quality management partnering for patient safety. By the ASHRM Monographs Task Force.

October 24, 2007

Adverse drug event surveillance and drug withdrawals in the United States, 1969-2002.

July 6, 2005

Developing a high value care programme from the bottom up: a programme of faculty-resident improvement projects targeting harmful or unnecessary care.

November 9, 2016

The SQUIRE Guidelines: an evaluation from the field, 5 years post release.

December 2, 2015

Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events.

May 18, 2011

Understanding the peer, manager, and system influence on patient safety.

February 10, 2021

Implementation of the safety huddle.

February 8, 2017

Sentinel events, serious reportable events, and root cause analysis.

March 25, 2015

The accuracy of the Global Trigger Tool is higher for the identification of adverse events of greater harm: a diagnostic test study.

March 22, 2023

Leveraging a safety event management system to improve organizational learning and safety culture.

March 30, 2022

Impact of high-reliability education on adverse event reporting by registered nurses.

October 10, 2018

Pediatric quality and safety: a nursing perspective.

May 11, 2016

Work-arounds observed by fourth-year nursing students.

November 19, 2014

The effect of a safe zone on nurse interruptions, distractions, and medication administration errors.

April 1, 2015

Medical line entanglement: the unspoken patient safety hazard of medical devices.

May 3, 2023

The girl who cried pain: a bias against women in the treatment of pain.

January 2, 2001

Standardizing hospital discharge planning at the Mayo Clinic.

January 12, 2011

Nurses improve medication safety with medication allergy and adverse drug reports.

October 3, 2007

Medication errors related to product names.

November 9, 2005

Medication errors involving wrong administration technique.

September 14, 2005

Patient outcomes after the introduction of statewide ICU nurse staffing regulations.

September 26, 2018

Safety in pediatric hospice and palliative care: a qualitative study.

September 23, 2020

The effectiveness of assertiveness communication training programs for healthcare professionals and students: a systematic review.

November 15, 2017

Electronic medical record: a balancing act of patient safety, privacy and health care delivery.

November 12, 2014

Benefits of direct observation in medication administration to detect errors.

January 9, 2008

Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: the Tompkins Acute Ward Study.

February 28, 2007

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

March 30, 2011

Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents.

October 3, 2018

Developing agreement on never events in primary care dentistry: an international eDelphi study.

August 29, 2018

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

August 25, 2021

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.

November 19, 2008

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.

June 7, 2023

Painting a picture of nurse presenteeism: a multi-country integrative review.

July 22, 2020

Related Resources

ISMP Medication Safety Intensive.

October 4, 2023 - October 5, 2023

Perspectives on Safety

Beyond the Pandemic: Creating Total Systems Safety

August 30, 2023

Perspectives on Safety

Interview

In Conversation with Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety

August 30, 2023

Judy Smetzer Just Culture Champion Scholarships.

August 16, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Systems approach to suicide prevention: strengthening culture, practice, and education.

June 28, 2023

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

May 24, 2023

Normalization of deviance is contrary to the principles of high reliability.

April 12, 2023

Diagnostic stewardship to prevent diagnostic error.

March 15, 2023

A failure in the medication delivery system-how disclosure and systems investigation improve patient safety.

January 11, 2023

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors.

October 12, 2022

Rooting an error review process in just culture: lessons learned.

October 5, 2022

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

June 29, 2022

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

May 6, 2022 - May 6, 2022

Error and cognitive bias in diagnostic radiology.

April 13, 2022

Improving responses to safety incidents: we need to talk about justice.

February 23, 2022

The morbidity and mortality conference: opportunities for enhancing patient safety.

February 9, 2022

Development and expression of a high-reliability organization.

December 1, 2021

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

September 29, 2021

Why accountability sharing in health care organizational cultures means patients are probably safer.

September 23, 2020

COVID-19: making the right diagnosis.

August 5, 2020

Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers

July 8, 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

Reducing diagnostic errors worldwide through diagnostic management teams.

April 3, 2019

Second victims need emotional support after adverse events: even in a just safety culture.

April 3, 2019

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

January 9, 2019

Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3.

December 19, 2018

Blame: what does it look like?

November 14, 2018

See More About The Topic

Hospitals

Health Care Providers

Quality and Safety Professionals

Pathology and Laboratory Medicine

Identification Errors

Reducing specimen identification errors.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Reducing specimen identification errors.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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