Developing and Pilot Testing Practical Measures of Preanalytic Surgical Specimen Identification Defects

Paul J. Bixenstine, Richard J. Zarbo, Christine G. Holzmueller, Gayane Yenokyan, Raymond Robinson, Daniel W. Hudson, Arlene M. Prescott, Ron Hubble, Mary M. Murphy, Chris T. George, Rita D'Angelo, Sam R. Watson, Lisa H. Lubomski, Sean M. Berenholtz

Research output: Contribution to journalArticlepeer-review

9 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)308-314
Number of pages7
JournalAmerican Journal of Medical Quality
Issue number4
StatePublished - Jul 2013


  • identification errors
  • labeling errors
  • quality measures
  • surgical pathology
  • surgical specimens

ASJC Scopus subject areas

  • Health Policy


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