Root cause analysis of specimen misidentification in surgical pathology accession and grossing

Laboratory Medicine

Volumn 39, Issue 8, 2008, Pages 497-502

  Dimenstein, Izak B ^a  

^a LOYOLA UNIVERSITY MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 59849097664     PISSN: 00075027     EISSN: None     Source Type: Journal    
DOI: 10.1309/B7KJB4QDM7YE35CV     Document Type: Article

References (8)

1. Association of Directors of Anatomic and Surgical Pathology Recommendations for Quality Assurance and Improvement in Surgical and Autopsy Pathology. Am J Surg Pathol. 2006;30:1469-1471.
2. D'Angelo R, Zarbo RJ. The Henry Ford Production System. Measures of process defects and waste in surgical pathology as a basis for quality improvement initiatives. Am J Clin Pathol. 2007;128:423-429.
3. Van der Schaaf TW. Near Miss Reporting in the Chemical Process Industry. 1992; Thesis, Eindhoven University of Technology, Eindhoven, The Netherlands.
4. Van VuurenW, Shea CE, Van der Schaaf TW. The Development of an Incident Analysis Tool for the Medical Field. Eindhoven, Netherlands: Eindhoven University of Technology; 1997
5. Battles JB, Kaplan HS, Van der Schaaf TW, et al. The attributes of medical event-reporting systems. Experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med. 1998;122:231-238.
6. College of American Pathologists Special Topic. Symposium on errors in pathology and laboratory medicine - Practical lessons for the pathologist. Arch Pathol Lab Med. 2005;129:1226-1276.
7. Makary MA, Epstein J, et al. Surgical specimen identification errors: A new measure of quality in surgical care. Surgery. 20007;141:450-455.
8. Zarbo RJ, D'Angelo R. The Henry Ford Production System. Effective Reduction of Process Defects and Waste in Surgical Pathology. Am J Clin Pathol. 2007; 128: 1015-1022.