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- Communication Improvement 2
- Error Reporting and Analysis 3
- Human Factors Engineering 1
- Logistical Approaches
- Quality Improvement Strategies 3
- Technologic Approaches 2
- Transparency and Accountability 1
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 6
- Identification Errors 2
- Medical Complications 1
- Medication Safety 1
- Surgical Complications 3
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Cases & Commentaries
- Web M&M
B. Joseph Guglielmo, PharmD; March 2007
Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.
PA-PSRS Patient Saf Advis. September 2005;2:1-5.
This article draws from the reporting system in Pennsylvania to discuss lost surgical pathology specimens and recommend a systems-oriented approach to improvement.
Journal Article > Study
Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.
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.
Journal Article > Study
Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out?
Suba EJ, Pfeifer JD, Raab SS. J Urol. 2007;178:1245-1248.
This study summarizes the findings from three root cause analyses to highlight the challenges in preventing patient identification errors in surgical pathology specimens. The authors suggest the use of a time-out strategy that would reduce the risk of the wrong patient receiving radiation or surgical therapy.
Journal Article > Review
Nakhleh RE. Arch Pathol Lab Med. 2008;132:181-185.
This review addresses surgical specimen analysis errors and highlights tactics to improve the reliability of the process.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.