Advertisement

Surgical specimen identification errors: A new measure of quality in surgical care

  • Martin A. Makary
    Correspondence
    Reprint requests: Martin A. Makary, MD, MPH, Assistant Professor of Surgery and Health Policy & Management, Johns Hopkins University, 4940 Eastern Ave, Building A-5, Baltimore, MD 21224.
    Affiliations
    Department of Surgery, Center for Surgical Outcomes Research, John Hopkins University School of Medicine, Baltimore, Md

    Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md

    Johns Hopkins Quality and Safety Research Group, Johns Hopkins Medical Institutions, Baltimore, Md
    Search for articles by this author
  • Jonathan Epstein
    Affiliations
    Department of Surgical Pathology, Center for Surgical Outcomes Research, John Hopkins University School of Medicine, Baltimore, Md
    Search for articles by this author
  • Peter J. Pronovost
    Affiliations
    Department of Surgery, Center for Surgical Outcomes Research, John Hopkins University School of Medicine, Baltimore, Md

    Department of Anesthesiology, Center for Surgical Outcomes Research, John Hopkins University School of Medicine, Baltimore, Md

    Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md

    Johns Hopkins Quality and Safety Research Group, Johns Hopkins Medical Institutions, Baltimore, Md
    Search for articles by this author
  • E. Anne Millman
    Affiliations
    Department of Surgery, Center for Surgical Outcomes Research, John Hopkins University School of Medicine, Baltimore, Md

    Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md

    Johns Hopkins Quality and Safety Research Group, Johns Hopkins Medical Institutions, Baltimore, Md
    Search for articles by this author
  • Emily C. Hartmann
    Affiliations
    Department of Surgery, Center for Surgical Outcomes Research, John Hopkins University School of Medicine, Baltimore, Md
    Search for articles by this author
  • Julie A. Freischlag
    Affiliations
    Department of Surgery, Center for Surgical Outcomes Research, John Hopkins University School of Medicine, Baltimore, Md
    Search for articles by this author
Published:January 26, 2007DOI:https://doi.org/10.1016/j.surg.2006.08.018

      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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Joint Commission on Accreditation of Healthcare Organizations
        Sentinel events: evaluating cause and planning improvement. Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL1998
        • Lingard L.
        • Espin S.
        • Whyte S.
        • et al.
        Communication failures in the operating room: An observational classification of recurrent types and effects.
        Qual Saf Health Care. 2004; 13: 330-334
        • Firth-Cozens J.
        Why communication fails in the operating room.
        Qual Saf Health Care. 2004; 13: 327
        • Espin S.
        • Levinson W.
        • Regehr G.
        • Baker G.R.
        • Lingard L.
        Error or “act of god”?.
        Surgery. 2006; 139: 6-14
        • Makary M.A.
        • Sexton J.B.
        • Freischlag J.A.
        • et al.
        Patient safety in surgery.
        Ann Surg. 2006; 243: 628-635
        • Edmonds C.R.
        • Liguori G.A.
        • Stanton M.A.
        Two cases of a wrong-site peripheral nerve block and a process to prevent this complication.
        Reg Anesth Pain Med. 2005; 30: 99-103
        • Gawande A.A.
        • Studdert D.M.
        • Orav E.J.
        • Brennan T.A.
        • Zinner M.J.
        Risk factors for retained instruments and sponges after surgery.
        N Engl J Med. 2003; 348: 229-235
        • Gawande A.A.
        • Zinner M.J.
        • Studdert D.M.
        • Brennan T.A.
        Analysis of errors reported by surgeons at three teaching hospitals.
        Surgery. 2003; 133: 614-621
        • Makary M.A.
        • Sexton J.B.
        • Freischlag J.A.
        • et al.
        Teamwork in the operating room: teamwork in the eye of the beholder.
        J Am Coll Surg. 2006; 202: 848-852
        • Raab S.S.
        • Grzybicki D.M.
        • Janosky J.E.
        • et al.
        Clinical impact and frequency of anatomic pathology errors in cancer diagnoses.
        Cancer. 2005; 104: 2205-2213
        • Safrin R.E.
        • Bark C.J.
        Surgical pathology sign-out.
        Am J Surg Pathol. 1993; 17: 1190-1192
        • Furness P.N.
        • Lauder I.
        A questionnaire-based survey of errors in diagnostic histopathology throughout the United Kingdom.
        J Clin Pathol. 1997; 50: 457-460
        • Renshaw A.A.
        • Young M.L.
        • Jiroutek M.R.
        How many cases need to be reviewed to compare performance in surgical pathology?.
        Am J Clin Pathol. 2003; 119: 388-391
        • McBroom H.M.
        • Ramsay A.D.
        The clinicopathological meeting.
        Am J Surg Pathol. 1993; 17: 75-80
        • Raab S.S.
        • Nakhleh R.E.
        • Ruby S.G.
        Patient safety in anatomic pathology: Measuring discrepancy frequencies and causes.
        Arch Pathol Lab Med. 2005; 129: 459-466
        • Nakhleh R.E.
        • Zarbo R.J.
        Amended reports in surgical pathology and implications for diagnostic error detection and avoidance: A college of American pathologists Q-probes study of 1,667,547 accessioned cases in 359 laboratories.
        Arch Pathol Lab Med. 1998; 122: 303-309
        • Raab S.S.
        • Grzybicki D.M.
        • Zarbo R.J.
        • Meier F.A.
        • Geyer S.J.
        • Jensen C.
        Anatomic pathology databases and patient safety.
        Arch Pathol Lab Med. 2005; 129: 1246-1251
        • Zarbo R.J.
        • Meier F.A.
        • Raab S.S.
        Error detection in anatomic pathology.
        Arch Pathol Lab Med. 2005; 129: 1237-1245
        • Makary M.A.
        • Holzmueller C.G.
        • Thompson D.
        • et al.
        Operating room briefings.
        Jt Comm Jour Qual Saf. 2006; 32: 351-355
        • Makary M.A.
        • Holzmueller C.G.
        • Sexton J.B.
        • et al.
        Operating room debriefings.
        Jt Comm Jour Qual Saf. 2006; 32: 407-410
        • Pronovost P.J.
        • Weast B.
        • Rosenstein B.
        • et al.
        Implementing and validating a comprehensive unit-based safety program.
        J Patient Saf. 2005; 1: 33-40
        • Pronovost P.J.
        • Nolan T.
        • Zeger S.
        • Miller M.
        • Rubin H.
        How can clinicians measure safety and quality in acute care?.
        Lancet. 2004; 363: 1061-1067
        • Lilford R.
        • Mohammed M.A.
        • Spiegelhalter D.
        • Thomson R.
        Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma.
        Lancet. 2004; 363: 1147-1154
        • Jha A.K.
        • Kuperman G.J.
        • Teich J.M.
        • et al.
        Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report.
        J Am Med Inform Assoc. 1998; 5: 305-314
        • Pronovost P.J.
        • Holzmueller C.G.
        • Martinez E.
        • et al.
        A practical tool to investigate defects in patient care.
        Jt Comm Jour Qual Saf. 2006; 32: 102-108