Farrell C‐JL, Giannoutsos J. Int J Lab Hematol. 2022;44:497-503.
Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review.
Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17:e615-e621.
Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.
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.
Seferian EG, Jamal S, Clark K, et al. BMJ Qual Saf. 2014;23:690-7.
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.
Salinas M, López-Garrigós M, Lillo R, et al. Clin Biochem. 2013;46:1767-9.
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.
Snydman LK, Harubin B, Kumar S, et al. Am J Med Qual. 2012;27:147-53.
This article uses data from a large database of voluntarily reported errors to characterize errors in laboratory medicine. Most errors occurred at the preanalytic phase (before the specimen arrived in the laboratory), with many errors arising from misidentification of specimens. The vast majority of the more than 30,000 errors analyzed did not lead to patient harm. A pathology misidentification error that resulted in disclosure of an incorrect diagnosis to a patient is discussed in this AHRQ WebM&M commentary.
Smith AF, Casey K, Wilson J, et al. Int J Qual Health Care. 2011;23:590-9.
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 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 column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.
This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.
This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.
This monthly selection of reports discusses an error involving the routing of a printed label in the pharmacy, describes examples of drug name confusion, and highlights an obscure drug concentration change.
This monthly selection of medication error reports includes information about the risks of cutting medication patches, describes examples of drug name confusion, and explains the importance of indicating the purpose for the medication on prescriptions.
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