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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 > Commentary
Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:982-984.
The authors recommend development of critical diagnosis guidelines for anatomic pathology and provide examples of possible critical diagnoses.
Dobbs D. New York Times Magazine. April 24, 2005;sect 6:40.
The author interviews experts who discuss the autopsy as a unique method for discovering medical mistakes and why it is not used more often as a teaching and improvement mechanism.