Selected bibliography supporting the ten essential objectives for safe surgery
8. The team will secure and accurately identify all surgical specimens.
Howanitz, P. J. (2005). "Errors in laboratory medicine: practical lessons to improve patient safety." Arch.Pathol.Lab Med. 129(10): 1252-1261.
- CONTEXT: Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies.
- OBJECTIVES: To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety.
- SETTING: A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature.
- DESIGN: Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures.
- MAIN OUTCOME MEASURES: A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors.
- RESULTS: Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification, specimen acceptability, proficiency testing, critical value reporting, blood product wastage, and blood culture contamination. Error rate benchmarks for these performance measures were cited and recommendations for improving patient safety presented.
- CONCLUSIONS: Not only has each of the 8 performance measures proven practical, useful, and important for patient care, taken together, they also fulfill regulatory requirements. All laboratories should consider implementing these performance measures and standardizing their own scientific designs, data analysis, and error reduction strategies according to findings from these published studies
Makary, M. A., J. Epstein, et al. (2007). "Surgical specimen identification errors: a new measure of quality in surgical care." Surgery 141(4): 450-455.
- BACKGROUND: Communication errors are the primary factor contributing to all types of sentinel events including those involving surgical patients. One type of communication error is mislabeled specimens. The extent to which these errors occur is poorly quantified. We designed a study to measure the incidence and type of specimen identification errors in the surgical patient population.
- METHODS: We performed a prospective cohort study that included all patients who underwent surgery in an outpatient clinic or hospital operating room and for whom a pathology specimen was sent to the laboratory. The study took place during a 6-month period (October 2004 to April 2005) at an urban, academic medical center. The study's main end-points were the incidence and type of specimen labeling errors in the hospital operating room and the outpatient clinic. The specimen was the unit of analysis. All specimens were screened for "identification errors," which, for the purposes of this study, were defined as any discrepancy between information on the specimen requisition form and the accompanying labeled specimen received in the laboratory. Errors were stratified by the type of identification error, source, location, and type of procedure.
- RESULTS: A total of 21,351 surgical specimens were included in the analysis. There were 91 (4.3/1000) surgical specimen identification errors (18, specimen not labeled; 16, empty container; 16, laterality incorrect; 14, incorrect tissue site; 11, incorrect patient; 9, no patient name; and 7, no tissue site). Identification errors occurred in 0.512% of specimens originating from an outpatient clinic (53/10,354 specimens) and 0.346% of specimens originating from an operating room (38/10,997 specimens). Procedures involving the breast were the most common type to involve an identification error (breast = 11, skin = 10, colon = 8); in addition, 59.3% (54/91) of errors were associated with a biopsy procedure. Follow-up was complete in all cases found to have an identification error.
- CONCLUSIONS: Surgical specimen identification errors are common and pose important risks to all patients. In our study, these events occurred in 4.3 per 1000 surgical specimens or an annualized rate of occurrence of 182 mislabeled specimens per year. Given the frequency with which these errors occur and their potential effect on patients, the rate of surgical specimen identification errors may be an important measure of patient safety. Strategies to reduce the rate of these errors should be a research priority
Troxel, D. B. (2004). "Error in surgical pathology." Am.J.Surg.Pathol. 28(8): 1092-1095.
- A total of 272 surgical pathology claims reported to The Doctors Company from 1998 through 2003 were reviewed. They were analyzed and repetitive patterns involving both specimen type and category of diagnostic error were identified. These patterns were then compared with those uncovered in a prior review of 218 surgical pathology claims reported from 1995 through 1997 to identify trends and see if new patterns of diagnostic error had emerged.
Wagar, E. A., L. Tamashiro, et al. (2006). "Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors." Arch.Pathol.Lab Med. 130(11): 1662-1668.
- CONTEXT: Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process.
- OBJECTIVE: To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools.
- DESIGN: Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics.
- RESULTS: Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P < .001) when compared to before implementation of the 3 patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months.
- CONCLUSIONS: Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.