This study examined more than 21,000 surgical specimens and estimated a surgical specimen identification error rate of 4.3 per 1000 specimens. Error rates were higher for specimens associated with a biopsy procedure and the outpatient setting. The authors point out that specimen mislabeling represents one type of communication error and that certain strategies may prevent these events. The Joint Commission has addressed specimen labeling in their National Patient Safety Goals; the ability of hospital systems to prevent these errors may serve as a marker of quality and safety.