Bixenstine Paul J, Zarbo Richard J, Holzmueller Christine G, Yenokyan Gayane, Robinson Raymond, Hudson Daniel W, Prescott Arlene M, Hubble Ron, Murphy Mary M, George Chris T, D'Angelo Rita, Watson Sam R, Lubomski Lisa H, Berenholtz Sean M
The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Am J Med Qual. 2013 Jul-Aug;28(4):308-14. doi: 10.1177/1062860612469824. Epub 2013 Jan 15.
Accurate patient identification is a National Patient Safety Goal. Misidentification of surgical specimens is associated with increased morbidity, mortality, and costs of care. The authors developed 12 practical, process-based, standardized measures of surgical specimen identification defects during the preanalytic phase of pathology testing (from the operating room to the surgical pathology laboratory) that could be used to quantify the occurrence of these defects. The measures (6 container and 6 requisition identification defects) were developed by a panel of physicians, pathologists, nurses, and quality experts. A total of 69 hospitals prospectively collected data over 3 months. Overall, there were identification defects in 2.9% of cases (1780/60 501; 95% confidence interval [CI] = 2.0%-4.4%), 1.2% of containers (1018/81 656; 95% CI = 0.8%-2.0%), and 2.3% of requisitions (1417/61 245; 95% CI = 1.2%-4.6%). Future research is needed to evaluate if hospitals are able to use these measures to assess interventions meant to reduce the frequency of specimen identification defects and improve patient safety.
