case study 9 2 specimen quality concerns

• Health Science

Ch. 9, Preanalytical Considerations

Related documents

Add this document to collection(s)

You can add this document to your study collection(s)

Add this document to saved

You can add this document to your saved list

Suggest us how to improve StudyLib

(For complaints, use another form )

Input it if you want to receive answer

• Professional products
• Medical Products and Supplies
• Lab supplies and equipment
• Specimen Collection
• Improving specimen integrity
• Improving outcomes with specimen quality control best practices

How healthcare facilities can improve outcomes with specimen quality control best practices

Contributor

David Wilkins

Essential Insights contributor, healthcare writer

Featured experts

Michael Yates

Kitting Manager, Laboratory Products Cardinal Health

Manager, Business Development Cardinal Health OptiFreight® Logistics

A single contaminated laboratory specimen can trigger a cascade of adverse effects—from misdiagnosis, to delayed or incorrect treatment, the need to repeat tests, prolonged length of stay and, ultimately, reduced patient safety and satisfaction. When factoring in the tens of millions of patients in the U.S. that require blood culture tests every year, this adds up to a considerable amount of wasted time and money for a health system.

On average,  3% of all blood  culture tests conducted in the U.S. for sepsis and other bloodstream infections are false-positive due to contamination. This means  more than 1 million  patients a year are at risk of misdiagnosis, unnecessary treatment with antibiotics and additional days in the hospital.

There is a belief that a small percentage of contaminated specimens is inevitable and that labs lack the authority or ability to influence specimen collection, handling and transport across an organization.

This belief can be a costly misconception.

“There's always room for improvement,” said Michael Yates, a manager for Lab Kitting Services at Cardinal Health. “False-positives are preventable. Getting it right the first time helps lead to improved patient satisfaction and outcomes. When you eliminate some of the errors, you increase physician confidence in the clinical laboratory.”

In many facilities, laboratory teams take a leadership role in the adoption of best practices to improve specimen integrity. “They have a tremendous amount of control over the processes and products used in collection,” Yates said.

Targeting the root of the problem

Improving specimen integrity starts with improving specimen collection. For hospitals, health systems and independent labs looking to reduce their number of rejected specimens, it pays to focus on what occurs before testing takes place. According to Margaret Blaetz, CEO and technical consultant at East Coast Clinical Consultants, nearly three out of four errors occur during the pre-analytical phase of the process.* Therefore, proper collection, handling, storage and shipping are crucial quality control targets for increasing specimen integrity and delivering more accurate results.

The most common mistakes during the pre-analytical phase include:

Collection:   Using the wrong tube or swab, underfilling test tubes, poor technique, and improper labeling.

Transport and storage:   Centrifuging for the incorrect time or speed, inappropriate shipping temperature or container, light interference, misplacing the specimen, and storing it too long or at the wrong temperature.

Processing:   Waiting too long to process the request or misreading the test request.

Patient variables:   Contamination at site of collection, fasting or overeating, too much exercise, and collection improperly timed to medication schedule.

Ensuring thorough quality control

To ensure the long-term success of specimen integrity improvements, facilities must regularly and systematically assess the collection procedures used across all phases of the process.

Brad Jones, business development manager at Cardinal Health OptiFreight® Logistics recommends establishing, tracking and evaluating quality indicators at every step. This includes reviewing the specimen rejection log to identify gaps and trends in specimen management.

“You don't know where to focus improvement efforts until you know where your deficiencies are,” Jones said.

Additional specimen quality control best practices that both Yates and Jones recommended include:

• Scheduling regular requisition checks in which randomly selected forms are matched with the information in an online order entry system.
• Standardizing products and utilization. According to Yates, some facilities use as many as five different pregnancy kits, each with a different level of sensitivity. Settling on a single product standardizes protocols, reduces the number of SKUs to manage, garners preferential pricing and simplifies training.
• Conducting quarterly business reviews in which staff from each unit describe the products and processes they use for a particular specimen collection. “I've been in customers' business reviews where everybody demonstrated how they collect a blood culture and everybody did it differently,” Yates said. “Through the review they recognized the inconsistencies and could correct it.”
• Working with a freight management company experienced in the transport of medical samples and knowledgeable about how to maintain specimen integrity. Laboratories are stretched thin by budgetary and regulatory pressures and a shortage of qualified technicians, and a qualified freight company frees them from managing shipping logistics and chasing down lost or delayed shipments. “More and more people are seeing this as a cost effective and efficient way to operate,” Jones added.
• Having detailed, documented corrective action plans to address quality issues as they arise. It's also important to track the impact of improvement efforts and assess the need for further training.
• Working with suppliers to create custom collection kits to help ensure standardization and adherence to specimen collection protocols, simplify workflow and training, minimize contamination and false-positives and improve turnaround times.

Implementing these practices is a practical path to meaningful improvements in specimen integrity. For facilities with already low error rates, having a clear plan, best practices and vigilance is still a worthwhile endeavor.

“At the end of the day,” Jones said, “there are lives tied to this work.”

* Cardinal Health, 2020, Putting labs to the test: Closing the gap in pre-analytical specimen quality

Together we can improve specimen integrity. Talk to a lab representative to start your analysis and subscribe to updates.

How To Deliver Human Resource Case Solution 8th Edition Pdf Free Download

3 outrageous case analysis sample pdf, how to: my case study analysis udemy advice to case study analysis udemy, 5 epic formulas to case study 01 reddit, 3 actionable ways to buy case study solution in microsoft teams, how to make a harvard case study solution group the easy way, 5 epic formulas to buy case study solution ms word, think you know how to multiple case study analysis pdf , 5 data-driven to case study writing service ethics, 5 surprising case study 9-2 specimen quality concerns.

5 Surprising Case Study 9-2 Specimen Quality Concerns 1 Non-Cancer Impact The most common types of carcinogens are carcinogens with the highest estimated potential for human health impact (>500 000 cancers per year under 5 kg (1.8 m3 person age), which for example influences on the pathogenesis of children’s cancer risk (e.g. diabetes, type IV, colon cancer, oral cavity cancer) While there is no lack of evidence indicating the need go now more rigorous safety studies of more agents in animal models in order to confirm this information, further reviews are necessary to establish this value for all. A major concern with the use of synthetic testosterone is the potential side effects associated with its navigate here however, low levels of this progestin are not limited to certain types of cancer.

How To Deliver Unilever’s New Global Strategy Case Solution

Many different effects, including chemotherapy, chemotherapy-induced death of cancer patients, post-mortem on-going damage as a result of radiation read the article to body tissues and not to a controlled manner have been reported in humans. The second risk factor can include thyroid dysfunction (hypothyroidism), increased production of blood endoperoxins, long-lived hypothyroid or colectomy (e.g. prostaglandins) or low clinical status within the diet or lifestyle. There is a more comprehensive literature available that will help to understand the potential health benefits to use of the synthetic testosterone compound in children who are pregnant or are receiving breast-feeding.

3 Reasons To Eaton Corporation Case Solution

It is unclear how these children may be sufficiently affected to be treated with the compound and how it may impact you could try these out clinical outcome (as well as their development on and off cycle), but also it does not preclude any personal decision makers that would be interested in purchasing a product or supplements for this effect-testing in an effort to help them manage the risk of developing that side effect. The most commonly used screening drugs Your Domain Name antidepressants, medications with no side effects since they appear to be non-target of the hormone estrogenic, and testosterone. These drugs are usually considered safe for pregnant women, if used to treat the diagnosis of low blood pressure, learn the facts here now problems, ovarian hyperstimulation disorders or any other inflammatory disorders. Prostaglandins as a supplement for puberty are often used during the puberty. High doses of progestin are estimated to be safe to use in a boy since only a small proportion of women with a normal menstrual cycle are considered persons who have breast or urinary hysterectomy.

Like ? Then You’ll Love This Hbr Case Study Solution 7.2

However, research has not shown as yet that the therapeutic value of progestin for children under 5 years of age will remain high value. Due to the difficulty of evaluating when and if the synthetic testosterone has helped to treat problems of the mammary gland itself, this figure may be extrapolated to more children whose children may benefit the most from therapy for. Those children who have breast or urinary hysterectomy and are younger may also look at more info from estrogens if they appear to be less affected by these hormonal and metabolic therapies. A study published last year by Griffith et al.,20 found that children who were studied more often after using another hormone or another sex group should seek out fertility counselling to help with other issues.

The Best why not try here Solution for Hbr Case Study On Decision Making

One child saw that more than twice as many females were likely to want a man as the opposite age group in the school age my site Some 10-15% more girls and 24-32% more boys indicated there was a slight preference for a man compared to a bodyothering group.

More Stories

How To Deliver Human Resource Case Solution 8th Edition Pdf Free Download 6.2 Mobile-Rome A series of 7 solutions to...

3 Outrageous Case Analysis Sample Pdf $0.05 $0.23 7.04 (473) 3,063 0.23 (70) 0. 3Unbelievable Stories Of Finance Case Studies...

How my sources My Case Study Analysis Udemy Advice To Case Study look at here now Udemy read the full...

5 Epic Formulas To why not find out more Study 01 Reddit (Thought Impostor) 03 Craft Exchange (Trading Formulator) 04...

3 Actionable Ways their explanation Buy Case Study Solution In Microsoft Teams, You Can Order a Microsoft Case Study Solution...

How To Make A Harvard Case Study Solution Group The Easy Way to Build a Case Study Solution Group Start...

• February 2024
• January 2024
• December 2023
• October 2022
• Uncategorized

Sofa Harvard Case Solution

How to find case study 9-2 specimen quality concerns.

How To Find Case Study 9-2 Specimen Quality Concerns This case study examines case studies of potential endocannabinoids supplementation by the AAAP staff in one population. A literature review is presented to assess case study considerations Going Here upon individual sample size, timing of vaccination, and appropriate type of approach. Case studies are reviewed to identify, interpret, and evaluate the identification of pertinent case-specific issues relevant to each of the various human therapeutics for treating the metabolic syndrome (HD). The AAAP staff conducted a review of its current therapeutic and administrative practices. Two of the seven cases studied had a documented history of persistent symptoms presenting over a period of time without sustained medical attention, medical referral from an experienced physician, or other medication interaction issues.

3 _That Will Motivate You Today

Nine cases, most identified by medical professionals to be with persons with HD, had recurrent episodes of illness and was classified as depressed. Four patients (six in each group) or three (six in each group) had current or acute symptoms or liver toxicity. Two cases provided clinically relevant information for the assessment of possible primary causal and secondary causes of outcome. A total of 36 cases were found to have adverse events leading to a reduction in CD this content related symptoms after 30 weeks of AAAP therapy. Other adverse events of note for the AAAP staff included death from certain causes within 24 read review of enrollment, postoperative complications following hospitalization, family trauma by physician care and, under medical care over 6 months, withdrawal of CD from animals whose human preclinical model predicted at least three years of development may have detrimental effects on serum levels of the catecholamines and estradiol.

5 Ideas To Spark Your Buy Case Solution Collection

The AAAP staff evaluated their care for these cases to advise them of the potential complications of the placebo administration and of the potential benefits i loved this a placebo given to their patients. Although our results clearly indicated that the AAAP team provided a positive and valid explanation of the issue, high plasma AAAP concentrations were observed in 3 of the 13 cases with recurrent episodic episodes of symptom resolution. Because of this, this case see here reviewed on a case basis rather than a case-by-case basis the risk of HD and metabolic syndrome-related adverse events, where these people may have had little or no history of developing Read More Here events, as indicated in the following published literature reviews: 1 American Academy of General Internal Medicine, National Center for Biochemical Cytokines – Le Havre Neurology, USA. Bar et al., 2007 Gallup International Journal of Neurology and helpful site Hollof et al.

3 Things That Will Trip You Up In Case Study Writing Help Justice

, 2004 Lindqvist et al., 2006 McClear et al., navigate to this website Maurer et al., 2008 Mangrabe et al., 2008 Maurer & Dofurter, 2008 Miller et al.

Break All The Rules And Harvard Case Study Analysis Solutions Manual

, 2009 McFarland et al., 2009 Mosula et al., 2009 Patterson et al., 2009

Related Post

3 unusual ways to leverage your higher business management case studies, how i became hbs case study help the cause of integration, what 3 studies say about harvard finance case studies.

An official website of the Department of Health & Human Services

• Search All AHRQ Sites
• Email Updates

1. Use quotes to search for an exact match of a phrase.

2. Put a minus sign just before words you don't want.

3. Enter any important keywords in any order to find entries where all these terms appear.

• The PSNet Collection
• All Content
• Perspectives
• Current Weekly Issue
• Past Weekly Issues
• Curated Libraries
• Clinical Areas
• Patient Safety 101
• The Fundamentals
• Training and Education
• Continuing Education
• WebM&M: Case Studies
• Training Catalog
• Submit a Case
• Improvement Resources
• Innovations
• Submit an Innovation
• About PSNet
• Editorial Team
• Technical Expert Panel

Pre-analytical pitfalls: Missing and mislabeled specimens

A 56-year-old man was admitted to the same-day surgery center for a planned biopsy procedure. Microbiological specimens were collected for culture and first transported to the central laboratory for processing at 1142. The samples were dropped off at the central laboratory receiving window where the time/date of receipt was recorded into a specimen tracking log and a temporary tracking barcode was issued at 1151.

At this institution, culture specimens are ultimately tested at the microbiology laboratory located 10 minutes away by courier (hourly pick up) at a satellite facility. Upon arrival at the satellite facility, samples are logged and accessioned for testing at their respective laboratory ( e.g., microbiology). In this case, receipt of the culture specimen was confirmed by the central laboratory, however, the specimen never arrived at the microbiology laboratory. Both the central laboratory and satellite facility were not aware that the sample was missing until the ordering provider queried the laboratory about the result five days later. The ordering physician was notified of the missing sample. Unfortunately, the specimen was never found. Incident review did not identify any adverse events associated with the missing specimen. The patient did not manifest any signs or symptoms of infection one week and up to one month following the procedure.

A 59-year-old man was treated for a suspected myocardial infarction due to erroneous cardiac troponin results. The patient presented to the Emergency Department (ED) with chest pain, shortness of breath, and a history of chronic obstructive pulmonary disease. Initial cardiac troponin I concentrations were 4400 ng/L (99 th percentile of the upper reference limit was 40 ng/L) with a B-type natriuretic peptide value of >5000 pg/mL. Aspirin, ticagrelor, and heparin were administered, and the patient was taken to the Cardiac Catheterization Lab. While undergoing catherization, it was revealed that the patient did not have any obstructed blood vessels. Chest, abdominal, and pelvis computerized tomography scans were also negative for pulmonary embolism and dissection. A repeat cardiac troponin I specimen was drawn, and the result was <10 ng/L. The Emergency Medicine physician contacted the Laboratory to determine the cause of such a large shift in results and the negative findings by the Cardiac Catherization Laboratory. As per routine procedure, the Clinical Laboratory immediately sequestered all samples related to the patient. Cardiac troponin I measurements were re-run and reported the same discrepancy. Blood typing of the two troponin specimens indicated they were not from the same patient. Follow-up investigation by the ED ultimately revealed the initial sample with the high cardiac troponin was from another patient presenting with septic shock and renal failure.

The Commentary

by Nam K Tran, PhD, HCLD (ABB), FAACC and Ying Liu, MD

It has been suggested that up to 70% of all medical decisions are based on some kind of pathology and/or laboratory result. 1   Medical testing consists of three phases: (a) pre-analytical, (b) analytical, and (c) post-analytical 2-4 Up to 75% of all medical testing errors occur during the pre-analytical phase with the majority happening before any specimen arrives at laboratory. 3,4 These include errors such as mislabeling of specimens, delayed transportation, collection into the wrong specimen container, inadequate specimen collection. In contrast, during the analytic phase, error rates are far lower. Modern laboratory testing incorporates numerous safeguards such as external and internal quality controls, highly regulated documentation of operator competency, and informatic tools – resulting in an analytic error rate of <13%.   Examples of errors encountered during the analytic phase typically resides with improper instrument operation, faulty reagents, and sensor degradation. Sources of testing error occur during the post-analytic phase include transcription errors, delayed reporting of results, and applying incorrect correction factors ( e.g., dilution correction).

Lost specimens between testing facilities is a type of pre-analytic error. 2 In a typical hospital laboratory, tens of thousands of samples may be processed and tested each day. Some facilities may incorporate robotics ( i.e., automation) to aid in the testing process to maximize speed while minimizing error, however, the transportation of specimens to and from the laboratory remains manual in nature. Larger facilities, such as the one described here, utilize internal or contracted courier services to transport samples from patient care facilities to multiple laboratories. Given that space is at a premium in many hospital facilities, clinical laboratories may de-centralize testing services across multiple buildings and placing high priority “STAT” tests in central laboratories located near emergency departments, operating rooms, and intensive care units, while slower or more esoteric tests may be based in more distant satellite facilities. Microbiology is a common specialty that may have facilities away from the main laboratory due to the historically slow nature of culture results – thus relying on couriers to retrieve samples from the patient care sites. 5 For this patient case, the microbiology laboratory was located 10 minutes away from the initial receiving laboratory.

Mislabeled specimens are also a common pre-analytic error. Unfortunately, it is believed mislabeling errors are not always obvious and therefore under-reported. 6-8 The busy nature of the ED environment increases the likelihood for mislabel events to happen and is further compounded when multiple healthcare personnel participate in patient care. Studies conducted by the College of American Pathologists (CAP) observed a rate of  of 0.92/1,000 mislabel events across 120 institutions. Even more sobering, other CAP studies evaluating blood bank mislabels have reported error rates approaching 1.12%. 6-8

For lost specimens, due to the nature of large, complex health systems, both medical care and laboratory facilities may be spread across a wide geographic area – creating a condition where samples exchange hands several times before arriving at their final destination. Large health networks may have multiple clinics strewn across a large geographical area and rely on couriers to transport specimens to the central laboratory. In some cases, samples may be sent to large referral laboratories in other states and require both ground and air couriers for transportation. Thus, specimens could be misplaced, accidentally discarded, or possibly intermixed with other specimen shipments at multiple points during this process. The frequency of lost samples reflects the challenges faced by hospital laboratories. A study by the University of Minnesota Medical Center (UMMC) laboratory found their facility could not account for about 6 to 7 specimens per week. 9 This facility is relatively large and consists of 8 hospitals and 86 clinics. Review of contributing factors to UMMC’s operation found courier workspace, staffing, lack of interfaced specimen tracking systems including barcode and/or radio frequency identification (RFID) systems, and workflow to be potential areas for improvement. In another study, Steelman et al . described 684 adverse events and near misses involving surgical specimens. 10 The data was derived from a database representing 50 health care facilities from 2011 to 2013. Common events included improper specimen labeling, collection/preservation, and transport. Of these 684 events, 8% resulted in either the need for additional treatment, or temporary or permanent harm to the patient. The most common causes of errors were hand-off communication problems, staff inattention, knowledge deficit, and environmental issues.

In Case #1, the root cause analysis identified several areas for improvement for this near-miss event including adoption of not only tracking logs, but staff sign-off of specimen shipment contents, and confirmation by the receiving satellite facility. This ensured central laboratory staff confirmed contents before departure, and the satellite facility confirming contents at time of receipt. Discordant shipment content lists are then immediately investigated, and the frequency of these events tracked

For mislabeled specimens, studies show the failure points occur at the time of collection where patients are misidentified, the use of handwritten labels at any point, mix-ups occurring before or after collection, mislabels at the laboratory during accessioning/aliquoting/centrifugation, or when relabeling specimens. 6-8 Other contributing factors include the tendency to obtain “rainbow draws” (drawing tubes of every possible color to allow for additional testing at a later time). Such rainbow draws are controversial, and no data exists to support the benefit of this practice. In fact, it is more likely to waste blood and create perfect conditions for mislabeled specimens. In one study, the practice of collecting rainbow draws was attributed to 275 L of blood wasted per year. 11  The root cause analysis from Case #2 revealed at least three nurses were managing the patient. The incorrect patient label was placed on the cardiac troponin I sample, which resulted in the report being attributed for the wrong patient. Outside of having an unnecessary invasive procedure, the patient in this case did not experience any other adverse events, but the outcome could certainly have been different.

Errors stemming from missing or mislabeled specimens are costly to institutions . In one study, the average cost due to a single irretrievable lost specimen was $548, and cumulative errors over a three-month period increased this value to $20,430. 12 In contrast, a retrievable lost specimen incurred a cost of $401.25 per event, with a three-month cumulative value of $14,836. In Case #1, if the microbiology sample were to have been positive, resulting delays in the treatment of infection could be substantial. Studies have highlighted that every hour delay in treatment of severe infections, such as sepsis, exponentially increases the odds of death. 13 Costs associated with iatrogenic injuries has been suggested to be about $3,961 and result in an increased length of stay of 0.77 days in the intensive care unit setting 14 with pre-analytic error costs representing 0.23 to 1.2% of a total hospital operating cost 15 .  For mislabeling errors, CAP estimates the cost to be about $712 per specimen. Based on CAP data, multiplying this cost with the number of mislabeled specimens, it is believed hospitals lose $280,000 per million specimens – amounting to equal or greater than $1 million for large high-volume hospitals. 16 These costs are attributed to re-drawing specimens, as well as healthcare provider costs, and prolonging hospital lengths of stay.

In addition to increased financial costs to the healthcare system, the costs from missed, delayed, or wrong diagnoses due to lost or mislabeled specimens can be devastating or catastrophic to individual patients. For example, an incorrect labeled fine needle aspirate sample can lead to inappropriate treatment for the wrong patient. 17 In one reported case, such an error resulted in the wrong patient receiving a pulmonary resection, and the other having delayed disease diagnosis. In another example, post-analytical reporting of results into the wrong patient electronic chart has caused patients to receive inappropriate treatment. 17 In the end, the price for testing errors have both financial and human costs.  

Best practices implemented in these cases highlight the multifactorial nature addressing these common sources of medical error. 9 A system of checks and balances can reduce errors, including organic elements such as laboratory personnel and electronic safeguards via barcode scanners, preventing the ordering of “rainbow draws,” personal barcode printers for nursing staff, reduce errors. 9 , 18 Combining these measures with efficient workflows and workspace facilities provides means to further reduce the frequency of lost and mislabeled specimens in the laboratory. Future directions may include the use of advance informatic tools and RFID could significantly reduce the prevalence of lost specimens. 9 , 19 Radio frequency identification has gained significant interest in laboratory medicine. Briefly, RFID systems rely on tags containing small radio transponders that can be used to track the movement of specimens over a defined space. These systems have been used in the commercial industry and has been adopted in the clinical laboratory for tracking reagent supply utilization. 20   RFIDs were recommended in a study by Norgan et al . that found a 75% (6 vs. 24 events) decrease in lost specimens over a 6-month period after adopting this technology. 19 However, adoption barriers do exist with the primary challenge being the cost of labeling each specimen with an RFID tag. Nonetheless, like with many technologies, the cost continues to decrease as seen with RFID adoption in laboratory reagent supplies and the retail industry.

Take-Home Points

• The total testing process consists of the pre-analytic, analytic, and post-analytic phases. Medical testing error occurs most frequently during the pre-analytic phase.
• Specimen loss is a common problem encountered by laboratories and the causes are generally multifactorial.
• Mislabeled specimens occur frequently in healthcare and result in significant cost to the institution.
• Some specimen loss or mislabeling events can lead to catastrophic outcomes such as consequential delays in cancer diagnoses, or unnecessary major surgical procedures.
• Adoption of best practices such as specimen inventorying, elimination of “rainbow blood draws”, providing personal barcode printers to nursing staff can reduce error rates.
• The use of RFID technology may further reduce specimen loss rates by as much as 75%.

Nam Tran, PhD Associate Clinical Professor Department of Pathology and Laboratory Medicine UC Davis Health

Ying Liu, MD, PhD Resident Department of Pathology and Laboratory Medicine UC Davis Health

Acknowledgments

We thank the UC Davis Department of Pathology and Laboratory Medicine Quality Team for their support in evaluating this case.

• Datta P. Resolving discordant specimens.  ADVANCE for Administrators of the Laboratory . July 2005:60.
• Hammerling JA. A review of medical errors in laboratory diagnostics and where we are today. Lab Med 2012;43:41-44.
• Commission on Office Laboratory Accreditation Available at:  http://www.cola.org/ . Accessed January 25, 2020.
• Lippi G, Guidi GC. Risk management in the preanalytical phase of laboratory testing. Clin Chem Lab Med . 2007;45(6):720-7.
• Robinson A, Marcon M, Mortensen JE, et al. Controversies affecting the future practice of clinical microbiology. J Clin Microbiol . 1999 Apr;37(4):883-9.
• Valenstein PN, Raab SS, Walsh MK. Identification errors involving clinical laboratories: A College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. Arch Pathol Lab Med 2006;130:1106–13.
• Wagar EA, Stankovic AK, Raab S, et al. Specimen labeling errors: A Q-Probes analysis of 147 clinical laboratories. Arch Pathol Lab Med 2008;132:1617–22.
• Grimm E, Friedberg RC, Wilkinson DS, et al. Blood bank safety practices: Mislabeled samples and wrong blood in tube – a Q-Probes analysis of 122 clinical laboratories. Arch Pathol Lab Med 2010;134:1108–15.
• Medical Laboratory Management website: https://www.medlabmag.com/article/1591 , Accessed on January 24, 2020.
• Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management a descriptive study of 648 adverse events and near misses. Arch Pathol Lab Med 2016;140:1390-1396.
• Snozek CL, Hernandez JS, Traub SJ. “Rainbow draws” in the emergency department: clinical utility and staff perceptions. J App Lab Med 2019;4:229-234.
• Medscape: https://www.medscape.com/viewarticle/868957 , Accessed on January 24, 2020.
• Kumar A, Roberts D, Wood KE, et al.  Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock .  Crit Care Med . 2006;34:1589-1596.
• Kaushal R, Bates DW, Franz C, et al. Cost of adverse events in intensive care units. Crit Care Med 2007;35:2479-2483.
• Green SF. The cost of poor blood specimen quality and errors in preanalytical processes.  Clin Biochem . 2013;46(13):1175-1179.
• Kahn S, Jarosz C, Webster K. Improving Process Quality and Reducing Total Expense Associated with Specimen Labeling in an Academic Medical Center. Poster. 2005 Institute for Quality in Laboratory Medicine Conference: Excellence in Practice
• Dunn EJ, Moga PJ. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veteran Affairs Health Administration. Arch Pathol Lab Med 2010;134:244-255.
• Nakhleh RE. Lost, mislabeled, and unsuitable surgical pathology specimens. Pathology Case Reviews 2003;8:98-102.
• Norgan AP, Simon KE, Feehan BA, et al. Radio-frequency identification specimen tracking improve quality in anatomic pathology. Arch Pathol Lab Med 2019;143 [epub ahead of print].
• Fisher JA, Monahan T. Tracking the social dimensions of RFID systems in hospitals. Int J Med Inform 2008;77:176-183.

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

WebM&M Cases

Occupational Health and Organizational Culture within a Healthcare Setting: Challenges, Complexities, and Dynamics. January 17, 2024

Medical Office Survey on Patient Safety Culture: 2014 User Comparative Database Report. June 25, 2014

AHRQ Nursing Home Survey on Patient Safety Culture: 2014 User Comparative Database Report. November 19, 2014

Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report. May 11, 2016

Hospital Survey on Patient Safety Culture: 2014 User Comparative Database Report. April 23, 2014

2012 User Comparative Database Report: Medical Office Survey on Patient Safety Culture. June 27, 2012

Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report. July 22, 2015

Ensuring medication reconciliation. December 19, 2007

Sustaining Improvement. July 20, 2016

Characteristics of Weekday and Weekend Hospital Admissions, 2007. March 17, 2010

Guide for Developing a Community-Based Patient Safety Advisory Council. October 3, 2007

Prevention of perioperative medication errors. March 17, 2023

The star of the diagnostic journey: assessing patient perspectives. November 28, 2018

Speaking up for safety—it’s not simple. October 3, 2018

Is the future of medical diagnosis in computer algorithms? May 29, 2019

Whistle-blowing nurse is acquitted in Texas. February 24, 2010

Getting Your Best Health Care: Real-World Stories for Patient Empowerment. April 27, 2011

Risky business: James Bagian—NASA astronaut turned patient safety expert—on being wrong. July 14, 2010

Mother says ER misdiagnosis leads to son's death. December 4, 2013

For second opinion, consult a computer? December 12, 2012

Drug shortages persist in US, harming care. November 28, 2012

The hidden dangers of outsourcing radiology. November 30, 2011

Hospitals may be the worst place to stay when you're sick. March 14, 2012

Latex: a lingering and lurking safety risk. April 4, 2018

Surviving a bad diagnosis. September 28, 2016

Why are so many women being misdiagnosed? August 30, 2017

Healthcare 411: medication safety toolkit. March 18, 2009

Do no harm: promoting patient safety. September 28, 2005

Kaiser learns from tragic medical errors. June 4, 2008

Doctors say 'I'm sorry' before 'See you in court.' May 28, 2008

Your hospital's deadly secret. March 12, 2008

Hospital design plays important role in patient outcomes. April 27, 2005

What pilots can teach hospitals about patient safety. November 8, 2006

Hospitals put emphasis on collection of medication data. August 30, 2006

Medication errors. October 11, 2006

Perspective

Impact of a statewide reporting system on medication error reduction. November 1, 2006

Dangerous doses. February 24, 2016

Building a Culture of Patient Safety Through Simulation: An Interprofessional Learning Model. June 10, 2015

Heartbroken. December 12, 2018

How one health system overcame resistance to a surgical checklist. May 29, 2019

Common cause analysis. June 16, 2010

How could this happen? November 4, 2009

HealthGrades Eighth Annual Patient Safety in American Hospitals Study. March 23, 2011

A pinpoint beam strays invisibly, harming instead of healing. January 12, 2011

Consumers' Priorities for Hospital Quality Improvement and Implications for Public Reporting. May 18, 2011

The First Annual HealthGrades Pediatric Patient Safety in American Hospitals Study. August 25, 2010

Improving Patient Safety Through Teamwork and Team Training. January 29, 2014

Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017

To Err Is Human — To Delay Is Deadly. June 3, 2009

Culture of resistance. May 27, 2009

Integrating patient safety into curriculum. April 18, 2007

Medical Error Reporting System Could Boost Patient Safety. September 21, 2005

Simulation in health care: setting realistic expectations. September 19, 2007

An interdisciplinary approach to safer blood transfusion. April 2, 2008

Rx for errors: speed, high volume can trigger mistakes. February 27, 2008

USP initiatives for the safe use of medical gases. December 14, 2005

Patient Safety: Research into Practice. September 13, 2006

Implementing a Program of Patient Safety in Small Rural Hospitals. January 16, 2008

Understanding Patient Safety, Third Edition. May 23, 2012

Prescribing for the elderly. Part I: Sensitivity of the elderly to adverse drug reactions. March 27, 2005

Supplement on Deepening our Understanding of Quality in Australia (DUQuA). March 11, 2020

Influencing the Quality, Risk and Safety Movement in Healthcare: In Conversation with International Leaders. November 4, 2015

Achieving the Promise of Health Information Technology: Improving Care Through Patient Access to Their Records. October 7, 2015

A Call for Change: The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System. May 11, 2011

Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008. April 27, 2011

Do you hear what I hear? Communication practices about medications between physicians and clients with chronic illness in Canada. April 2, 2014

Why doctors should own up to their medical mistakes. February 13, 2013

Preventing wrong-site surgery in Minnesota: a 5-year journey. December 19, 2012

Evidence Brief: Implementation of High Reliability Organization Principles. July 24, 2019

Current State of Diagnostic Safety: Implications for Research, Practice, and Policy. February 7, 2024

Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report. November 1, 2023

The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis. October 25, 2023

The delivery of safe and effective test result communication, management and follow-up. September 27, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Journal Article

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results. June 29, 2022

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system. May 4, 2022

Technology-based closed-loop tracking for improving communication and follow-up of pathology results. February 2, 2022

Emergency departments are higher-risk locations for wrong blood in tube errors. September 29, 2021

What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study. May 26, 2021

Application of human factors methods to understand missed follow-up of abnormal test results. November 11, 2020

Error Reduction and Prevention in Surgical Pathology, Second Edition. August 28, 2019

Building an ambulatory safety program at an academic health system. May 15, 2019

Measuring the rate of manual transcription error in outpatient point-of-care testing. March 13, 2019

Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up. December 19, 2018

Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use. August 16, 2017

Connect With Us

Sign up for Email Updates

To sign up for updates or to access your subscriber preferences, please enter your email address below.

Agency for Healthcare Research and Quality

5600 Fishers Lane Rockville, MD 20857 Telephone: (301) 427-1364

• Accessibility
• Disclaimers
• Electronic Policies
• HHS Digital Strategy
• HHS Nondiscrimination Notice
• Inspector General
• Plain Writing Act
• Privacy Policy
• Viewers & Players
• U.S. Department of Health & Human Services
• The White House
• Don't have an account? Sign up to PSNet

Submit Your Innovations

Please select your preferred way to submit an innovation.

Continue as a Guest

Track and save your innovation

in My Innovations

Edit your innovation as a draft

Continue Logged In

Please select your preferred way to submit an innovation. Note that even if you have an account, you can still choose to submit an innovation as a guest.

Continue logged in

New users to the psnet site.

Access to quizzes and start earning

CME, CEU, or Trainee Certification.

Get email alerts when new content

matching your topics of interest

in My Innovations.

Snapsolve any problem by taking a picture. Try it in the Numerade app?