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This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.
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Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.
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Saufl NM. J Perianesth Nurs. 2009;24:114-8.
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Cohen MR.
This monthly commentary examines risks associated with mismanagement of IV tubing and ports, discusses a recent article regarding unintended consequences of computerized provider order entry (CPOE), and details recent changes to similarly named medications.
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Kowalczyk L
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
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Cohen MR.
This monthly selection of medication error reports provides examples of problems related to abbreviations, electronic prescribing, and communication of critical lab values.
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Landro L.
This article reports on initiatives to standardize the color designations of color-coded wristbands to avoid confusion and reduce the risk of error.
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Renshaw AA, Kish R, Gould EW. Am J Clin Pathol. 2007;127:271-2.
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Skibinski KA, White BA, Lin LI-K, et al. Am J Health Syst Pharm. 2007;64:90-6.
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A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.
