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This commentary reveals insights from a physician who was involved in a misidentified specimen incident. The author explains how the organization performed a root cause analysis to determine safety gaps in specimen handling processes and recommends four key steps to prevent errors.

This quality improvement initiative used human factors approaches including failure mode and effect analysis, event review, and root cause analysis to successfully reduce the rate of specimen mislabeling in an inpatient setting. This study highlights the importance of re-examining longstanding work processes to augment safety.

Although electronic test ordering resulted in fewer patient identification errors in a clinical laboratory, significant variability in error rates between centers remained, emphasizing the continued effect of human behavior on interventions.

Color-coded wristbands are often used to identify patients and alert providers to specific safety considerations, such as allergies. This study used human factors engineering principles to examine how wristbands were used for safety purposes at two British hospitals.

This study found a significant reduction in mislabeled blood specimens after implementing barcode technology.

This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.

This monthly article discusses incidents involving dosing errors and describes strategies to promote the safe use of oral syringes.