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)

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

December 16, 2015

Safety incidents in the primary care office setting.

May 20, 2015

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

February 1, 2017

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

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

April 1, 2020

Exposures to structural racism and racial discrimination among pregnant and early post-partum Black women living in Oakland, California.

January 23, 2020

Operational failures detected by frontline acute care nurses.

March 29, 2017

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

April 27, 2016

Implementing standardized reporting and safety checklists.

June 1, 2011

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

October 2, 2013

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

June 28, 2017

HIM functions in healthcare quality and patient safety.

August 10, 2011

Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study.

January 22, 2014

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States.

April 4, 2012

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

August 12, 2009

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

October 5, 2022

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

March 30, 2011

Standardized assessment of medication reconciliation in post-acute care.

April 27, 2022

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

March 16, 2016

A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors.

June 27, 2018

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

August 12, 2009

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

October 26, 2005

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

2008 Annual National Patient Safety Foundation Congress: conference proceedings.

September 24, 2008

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

March 6, 2005

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

Communication between primary and secondary care: deficits and danger.

August 21, 2019

Using social and behavioural science to support COVID-19 pandemic response.

June 3, 2020

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

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

October 22, 2014

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

April 10, 2019

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

May 2, 2012

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

October 24, 2018

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

November 22, 2017

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

August 23, 2017

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

January 31, 2018

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

August 30, 2023

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

June 4, 2008

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

December 8, 2021

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

February 3, 2016

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

August 7, 2019

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

May 15, 2019

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

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

May 18, 2011

ACGME duty-hour recommendations—a national survey of residency program directors.

August 11, 2010

A systems approach to morbidity and mortality conference.

July 28, 2010

Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns.

January 30, 2013

Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors.

July 11, 2012

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

November 29, 2017

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

January 29, 2020

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

July 23, 2008

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

November 25, 2020

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Simulation in the executive suite: lessons learned for building patient safety leadership.

January 6, 2016

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

August 6, 2014

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

June 12, 2019

Iatrogenic psychological harm.

November 30, 2011

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

June 7, 2017

Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study.

November 29, 2017

Emergency department volume and delayed diagnosis of serious pediatric conditions.

February 28, 2024

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

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

October 15, 2008

Nurses' perceptions and demands regarding COVID-19 care delivery in critical care units and hospital emergency services.

December 2, 2020

Technology-induced errors associated with computerized provider order entry software for older patients.

August 23, 2017

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

October 17, 2012

Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system.

September 9, 2020

Accuracy of practitioner estimates of probability of diagnosis before and after testing.

May 5, 2021

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

April 21, 2021

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

The effects of three consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: a quasi-experimental study.

October 20, 2021

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

November 18, 2020

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales.

November 11, 2020

Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme.

January 19, 2022

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

January 12, 2022

Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation.

December 15, 2021

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

Methods for studying medication safety following electronic health record implementation in acute care: a scoping review.

January 10, 2024

Unsafe care in residential settings for older adults. A content analysis of accreditation reports.

December 13, 2023

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review.

August 16, 2023

Dashboard design to identify and balance competing risk of multiple hospital-acquired conditions.

July 13, 2022

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

Understanding complexity in a safety critical setting: a systems approach to medication administration.

April 26, 2023

A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program.

April 26, 2023

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

April 19, 2023

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.

May 27, 2020

Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis

October 9, 2019

Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths

October 2, 2019

Implementation of the World Health Organization Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on care process measures.

November 30, 2016

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

September 26, 2018

Failures in the respectful care of critically ill patients.

October 10, 2018

Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: a randomized crossover trial.

September 16, 2015

Color-coded prefilled medication syringes decrease time to delivery and dosing error in simulated emergency department pediatric resuscitations.

March 25, 2015

How safe is primary care? A systematic review.

January 13, 2016

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

December 2, 2015

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

March 6, 2019

Quality improvement priorities for safer out-of-hours palliative care: lessons from a mixed-methods analysis of a national incident-reporting database.

February 6, 2019

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System—MEADERS.

December 1, 2010

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

ISMP Medication Safety Intensive.

March 12, 2024

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

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

Implementation of a colour-coded universal protocol safety initiative in Guatemala.

August 8, 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

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