Bibliographic Information - Author (s) - Yr Published/Submitted - Publication - Author Affiliations - Funding	Study - Design - Facility/Setting - Time Period - Population/Sample - Comparator - Study bias	Practice - Description - Duration - Training - Staff/Other Resources - Cost	Outcome Measures - Description (s) - Recording method	Results/Findings - Type of Findings - Findings/Effect Size - Stat. Significance/Test(s) - Results/Conclusion Bias
Bologna LJ and Mutter M - 2002 - J Healthcare Information Manag. - The Valley Hospital, Ridgewood NJ - Funding: not reported	- Design: Before-After - Facility/Setting: Valley Hospital, Ridgewood, NJ; > 400- bed community hospital - Time period: 1/1999 – 9/2000 Pre: 1 year (1/1999–12/1999) Post: 9 mos. (1/2000–9/2000) Population/Sample: Number of phlebotomies for 10 units: Pre: 69,432 Post: 59,490 - Comparator: Combination of print and hand-written labels used - Study bias: None noted	-Description: Barcoding system with portable label printer; labels printed at bedside - Duration: 9 months (1/2000 – 9/2000); ongoing - Training: not discussed - Staff/Other resources: Nursing supervisor, licensed medical practitioners, phlebotomists; portable label printers, BD System Software; bar-coded wristbands - Cost: not reported	- Description: Error Rates (1) Incorrect/incomplete specimen label (misidentified specimen) (2) Misidentified patients (3) Unnecessary phlebotomy - Recording Method: Pre: Not reported Post: Barcoding system automatically collects via built in reporting capabilities	- Pretest-Posttest - Findings/Effect Size: Error Rates (10 care centers: (1) Incorrect/incomplete specimen label (misidentified specimen): Pre: 0.017% (12/69,432) Post: 0.007% (4/59,490) Absolute decrease: 0.01% Relative decrease: 58.8% ➢ OR = 2.57 (CI: 0.83 – 7.97) (2) Misidentified patients: 94% reduction, pretest: 0.049% (34/69,432) posttest: 0.003% (2/59,490) ➢ OR = 29 (CI: 4 – 212) (3) Unnecessary phlebotomy: 89% reduction pretest: 0.027% (19/69,432) posttest: 0.003% (2/59,490) ➢ OR = 16.01 - Statistical Significance/Test(s): not discussed - Results/conclusion biases: None noted
Quality Rating: 7 (Fair) (10 point maximum) Effect Size Magnitude Rating: Moderate (Relevance: Direct)	Study (3 pts maximum): 3	Practice (2 pts maximum): 2	Outcome measures (2 pts. maximum): 1; Recording method: Not reported for pre period	Results/findings (3 pts maximum): 1; Appropriateness of statistical analysis: Pre and Post estimates appear to rely on different recording methods
- Brown JE [1], Smith N [1], Sherfy B. [2] - 2010 - Journal of Nursing Care Quality [1] Howard County General Hospital, member of Johns Hopkins Medicine [2] University of Maryland Medical Center - Funding: Self-financed *Additional study sample size information not in publication. Source: E-mail communication 7/12/2011 from Susan Neal-Lyman, Johns Hopkins Dept. of Pathology at Howard County General Hospital)	- Design: Before-after - Facility/Setting: Howard County General Hospital, Columbia, MD: 227-bed, nonprofit acute care community hospital – 6 inpatient units (3 med/surg, intermediate care, psychiatry, and obstetrics) - Time Period: 11/2005 – 10/2007 Pre: 1 yr. (11/2005 – 10/2006) Post: 1 yr. (11/2006–10/2007) - Sample: Inpatient blood specimens – totals* Pre: 456,069 Post: 458,461 - Comparator: Decentralized phlebotomy system with patient care technicians (PCTs) and RNs printing specimen labels at nurse’s station central printer; implemented methods and education to decrease errors. - Study bias: Barcoding implemented in one unit and after one month the other 5 units in post period one noted	- Description: Specimen positive patient identification system integrated with hospital, lab and physician order entry information systems for printing barcoded specimen labels at the bedside using a portable label printer generated from laboratory orders entered from an order management system -Duration: 12 mos. - Implemented 11/2006 in limited number of units; subsequently expanded hospital-wide over 3 years; ongoing -Training: 1 hour staff training, one week of 24-hour support during implementation, and “extensive” training/educational program -Staff/Other Resources Staff: Patient care technicians (PCTs) and registered nurses Other resources: portable label printers, portable handheld or beside computer including a barcode scanner, patients’ barcoded Identification band - Cost: Not reported	- Description: Specimen labeling errors/rate (# and %): Wrong patient name or specimens with multiple patient names in one specimen bag Additional qualitative benefits (no data): - Avoiding unnecessary patient discomfort and inconvenience for redrawing specimens - Preventing treatment delays - Eliminating nursing and laboratory staff rework - Recording method: Adverse event reports for specimen labeling errors entered by nursing and lab personnel; paper event- reporting system 2005- 3/2007; afterward web- based reporting	- Pretest-Posttest - Findings/Effect Size specimen labeling errors per 10,0000 specimens Pre: 2.26 (103/456,069 = 0.0226%) Post: 0.17 (8/458,461 = 0.0017%) Absolute decrease: 0.02% Relative decrease: 92.5% ➢ OR = 12.95 (CI: 6.31 – 26.58) - Stat. Significance/Test(s): None provided in published article for error rates as calculated above using total specimens; Mann-Whitney U Test showed a significant difference in the mean number of errors for the 2 periods (p <.001) - Results/Conclusion Bias: None
Quality Rating (10 point maximum): 9 (Good) Effect Size Rating: Substantial (Relevance: Direct)	Study (3 pts maximum): 2; Potential study bias - Barcoding implemented in one unit and then after one month the other 5 units in post period	Practice (2 pts maximum): 2	Outcome measures (2 pts maximum): 2	Results/findings (3 pts maximum): 3
Fabbretti G. - 2010 - Pathologica - Infermi Hospital. Rimini, Italy. - Funding: Self-funded	- Design: Observational, Non- comparative. - Facility/Setting: Infermi Hospital. Rimini, Italy. Pathology Lab.; no additional information reported - Time period: 2009 Post only: 1 year (dates not specified) Population/Sample: Histo-cytological samples. Post: 34,932 - Comparator: Handwritten request forms. - Study bias: None noted	-Description: Database and lab information system integrated using HL7 messages for patient ID data to be acquired from hospital records and transferred to local database. Examination phase: ID code obtained using barcode reader and automatically printed on cassette. Cutting phase: ID code printed directly on slide. - Duration: 5/2008–2009; ongoing - Training: 2-months immediately preceding implementation. Given in classrooms equipped with PCs to medical and paramedical staff who work in OR; other staff followed. - Staff/Other resources: 8 doctors, 4 biologists, 14 biomedical technicians, 2 admin assistants. IT Dept, Pathology Lab, medical, nursing and administrative staff of various hospitals in Rimini. Two databases and lab information system. - Cost: Not reported	- Description: Error Rates (1) Misinterpretation of handwritten data on request forms and sample labels (2) Mismatch of patient and/or specimen - Recording Method: Pre: Manual data transcription and handwritten requests forms. Post: Request and labels data recorded twice (printed by machine and on barcode). System identifies patient access by date and test type.	- Noncomparative - Findings/Effect Size: Error Rate: 0.27% (94/34,932) - Statistical Significance/Test(s): Not reported - Results/conclusion biases: None noted
Quality Rating: 5 (Poor*) (10 point maximum) Effect Size Magnitude Rating: (Relevance: Direct) *0 Outcome Measure rating	Study (3 pts maximum): 2 - Study Setting: Sufficiently distinctive that results may not be generalizable to other settings/specimens – Surg. path. specimen cassettes	Practice (2 pts maximum): 2	Outcome measures (2 pts. maximum): 0; Face Validity -Outcome measure confounded by practice itself (no comparison)	Results/findings (3 pts maximum;: 1; Appropriateness of statistical Analysis- Insufficient data to allow/verify calculation of effect size without comparison practice
Hayden RT, Patterson DJ, Jay DW, Cross C, Dotson P, Possel RE, Srivastava DK, Mirro J, and Shenep JL. - 2008 - Journal of Pediatrics - St. Jude’s Children’s Research Hospital (multiple departments), Memphis, TN, USA - Funding: Partly self- financed; and supported by the American Lebanese Syrian Associated Charities	- Design: Before-after - Facility/Setting: St. Jude Children’s Research Hospital, Memphis, TN ; pediatric cancer center - Time period: 9/2003 – 8/2006; 36 months Pre: 1 year (9/2003 – 8/2004) Staged implementation: 1 year Post: 1 year (9/2005 – 8/2006) - Population/Sample: Accessions of all tissue and body fluid specimens (test ordering events) approximating number of labeled containers. Excludes samples collected during system downtime, off site and by cardiac arrest team. Pre: 19,247 mean accessions per month (1 year) Post: 17,793 mean accessions per month (1 year) - Comparator: Not reported - Study bias: None noted	- Description: Electronic Positive Patient Identification (EPPID) system with barcoding. Handheld personal digital assistants in each patient, clinic and procedure room with scanner to track and verify clinician entered orders at point of collection; labels printed centrally at nursing station. - Duration: 12 – 24 mos. (staged implementation); ongoing - Training: 3-week training led by nurses. Included in-depth “train-the-trainer” for “super- users; end-user training on routine hardware and software process with hands-on training. Computer-based modules with hands-on training for new staff during employee orientation. - Staff/Other Resources: Nurses (all specimen collections by nursing staff) - Cost: Not reported	- Description: Mislabeled specimens (# and % of total accessions): mismatches between patient name and. specimen (wrong label used or specimen collected from wrong patient). - Recording Methods: QA data collected (method not specified) based on telephone notifications: 1) nursing alerting lab of labeling error; 2) test results for patients no longer in- house; 3) inquiries to lab about patient results from whom no sample received; 4) lab results discordant with earlier patient results	- Pretest-Posttest - Findings/Effect Size: Monthly mean mislabeled specimen error rate: Pre: 0.032% Post: 0.005% Absolute decrease: 0.03% Relative decrease: 84.4% ➢ OR = 6.58 (CI: 5.26–8.22) - Statistical Significance/Test(s): p < .001 exact Wilcoxon rank sum test - Results/conclusion biases: None noted
Quality Rating: 8 (Good) (10 point maximum) Effect Size Magnitude Rating: Substantial (Relevance: Direct)	Study (3 pts maximum): 3;	Practice (2 pts maximum): 2	Outcome measures (2 pts maximum): 1; Recording method not specified	Results/findings (3 pts maximum): 2; Appropriateness of statistical analysis: Comparison practice and recording method not specified; may differ for practices
Hill PM [1,2], Mareniss D [1,2], Murphy P [2], Gardner H [2], Hsieh Y [1], Levy F [1,2], Kelen GD [1,2] - 2010 - Annals of Emergency Medicine [1] Dept. of Emergency Medicine, Johns Hopkins Univ. School of Med. [2] Johns Hopkins Hospital - Funding: Self-financed	- Design: Before-after observational cohort study - Facility/Setting: Johns Hopkins Hospital, Baltimore, MD: Large, urban, university- based academic, adult emergency department (ED) with annual census of 57,000 - Time Period: 9/2004 – 9/2009 Pre: 44 mos. (9/2004 – 4/2008) Post: 17 mos. (5/2008 – 9/2009) - Sample: All specimens collected in the ED and sent to any hospital laboratory Pre: 724,465 Post: 345,039 - Comparator: Manual specimen ordering and labeling process; nurse stamps blank labels using embosser with plastic patient id card Study bias: Many post-period errors from manually processed specimens (not barcoded); some from work-arounds, but may include errors that should be excluded (blood bank, tissue, Level 1 trauma and critical care).	- Description: 2-component intervention: ED electronic documentation and information system integrated with the LIS including physician order entry combined with bar-code technology linked to patient’s identity; physician order entry generates printed barcode specimen labels near patient’s room. Not used for blood bank, tissue, Level I trauma and severe critical care specimens - Duration: 17 months (5/2008- 9/2009); ongoing - Training: Not reported - Staff/Other Resources Staff: Nurses and clinical technicians; Other Resources: Electronic documentation and information system integrated with a laboratory information system and physician order entry system, patient wristbands containing a patient identify barcode, label printers, specimen containers, scanners and labels - Cost: Not reported	- Description: Specimen processing error rate (total) including 4 separate types: unlabeled/mislabeled/wrong patient specimen or requisition; tabulated monthly -Recording method Monthly monitoring reports from normal quality assurance program clinical pathology information system records. Data from the Pre and Post periods were tabulated monthly. Limitation: Outcome measure includes unlabeled specimens – barcoding practice associated with barcoded labels	- Pretest-Posttest - Findings/Effect Size: error rate; Pre: 0.42% (3,007/724,465) Post: 0.11% (379/334,039) Absolute decrease: 0.3% Relative decrease: 73.8% ➢ OR = 3.67 (CI: 3.30 – 4.08) - Stat. Significance/Test(s) 0.31% absolute reduction; 95% C.I.: 0.28% to 0.32%; Chi-squared test - Results/Conclusion Bias: None
Quality Rating (10 point maximum): 9 (Good) Effect Size Rating: Substantial (Relevance: Direct)	Study (3 pts maximum): 2 Potential study bias - Errors and specimens from non- barcoded specimens not explicitly excluded	Practice (2 pts maximum): 2	Outcome measures (2 pts maximum): 2	Results/findings (3 pts maximum): 3
Killeen JP, Chan TC, Jones K, and Guess DA - 2005 - Academic Emergency Medicine - University of California, San Diego, CA, USA - Funding: Self-financed	- Design: Before-after - Facility/Setting: UCSD Medical Center, San Diego CA, academic medical center emergency department – Time Period: Two 6-month periods (Pre and Post); dates not reported - Sample: All Emergency Department (ED) patients seen during study period (annual census: 40,000) with ancillary ED laboratory tests Total ED laboratory specimens: Pre: 22,243 Post: 22,574 - Comparator: Imprint stamp sticker labels on specimens and paper requisitions -Study limitation: Unclear if 6- month periods being compared are immediately before and after implementation.	- Description: Barcoding system with electronic requisitions and computerized physician order entry (CPOE). Label printing location not specified. - Duration: 6 months duration; no dates provided -Training: not discussed - Staff/Other Resources: not discussed - Cost: not reported	- Description: PSID Error Rate - Number of misidentified, unlabeled, or mislabeled specimens per 1,000 specimens - Recording Methods: Prospectively collected – recording method not described	- Pretest-Posttest - Findings/Effect Size: PSID Error rate Pre : 2.56 per 1,000 [CI: 1.94–3.32] (0.26% = 57/22,243) Post: 0.49 per 1,000 [CI: 0.24–0.87] (0.05% = 11 /22,574) Absolute decrease: 0.2% Relative decrease: 80.8% ➢OR = 5.27 (CI: 2.76–10.05) - Statistical Significance/Test(s): p <.05 ; Chi-square test - Results/conclusion biases: None noted
Quality Rating: 9 (Good) (10 point maximum) Effect Size Magnitude Rating: Substantial (Relevance: Less Direct)	Study (3 pts maximum): 3	Practice (2 pts maximum): 2	Outcome measures (2 pts maximum): 1; Recording method not described	Results/findings (3 pts maximum): 3
- Morrison AP [1,2], Tanasijevic MJ [2], Goonan EM [2], Lobo MM [2], Bates MM[1], Lipsitz SR [1], Bates DW [1], Melanson SEF [2] - 2010 - American Journal of Clinical Pathology - Brigham and Women’s Hospital, Harvard Medical School, Boston, MA [1] Dept. of Medicine [2]Dept. of Pathology, Clinical Laboratories Division - Funding: Self-financed	- Design: Before-after - Facility/Setting: Brigham and Women’s Hospital, Boston, MA, a 777-bed academic medical center - Time period: 10/2007 – 6/2009 Pre: 10 mos. (10/2007 – 7/2008) Post: 10 mos. (9/2008 – 6/2009) - Sample: All inpatient care phlebotomy service blood collections (about 50% of total inpatient; excludes neonatal ICUs and patients on contact precautions) Pre: 181,758 Post: 184,043 - Comparator: Manually pre- printed patient addressograph labels attached to a correct matched requisition for phlebotomy rounds. - Study Bias: Only phlebotomist collections (15% of ID errors); subsequent use expanded to non-phlebotomists with higher error rates. Post-implementation less than 100% barcoding (reported 85% in 8th month).	- Description: Barcoding mobile system; handheld computers with barcode scanners, patient barcoded wristbands, mobile printers and integrated wireless radio and interfaced with hospital patient information system. Specimens labeled at bedside (no preprinted labels). No CPOE. - Duration: 18 mos. (8/2008 – 6/2009); ongoing - Training: 1.5 hour group introductory sessions followed by individual training of each phlebotomist accompanied by an experienced user and then individual additional training/education as needed - Staff/Other resources: Initial implementation: 20 handheld systems purchased for a team of 39 inpatient phlebotomists covering 3 daily shifts - Cost: Not reported	- Description: Incorrectly labeled samples – monthly number and rate: (1) Mislabeled (2) Unlabeled (3) Overall = (1)+ (2) - Recording Method Pre: Lab staff compared patient identifiers on specimen label and requisition form at receipt. Recorded as mislabeled if identifiers did not match or later determined sample from a different patient; without labels recorded as unlabeled. Post: Audit data collected by electronic ID system detected mismatches when scanning patient wristband before specimen collection; created a mismatch alert preventing a wrong- patient sample draw.	-Pretest-Posttest - Findings/effect size: Overall labeling error rate per 10,000 Pre: 5.45 (95% CI: 4.47 – 6.63) Post: 3.20 (95% CI: 2.48 – 4.14) Absolute decrease: 0.02% Relative decrease: 41.3% ➢ OR = 1.70 (CI : 1.23–2.35) Mislabeled: 43% reduction Pre: 0.030% (55 errors) Post: 0.017% (32 errors) Unlabeled: 38% reduction Pre: 0.024% (44 errors) Post: 0.015% (27 errors) - Stat. Significance Test: Logistic regression used to model rates over time and for statistical significance and confidence interval estimates; before and after changes tested via Wald statistics; p = 0.0013 - Results/Conclusion Bias: None noted
Quality Rating (10 point maximum): 7 (Fair) Effect Size Rating: Moderate (Relevance: Direct)	Study (3 pts maximum): 2 Potential study bias – phlebotomists only and <100% barcoding may understate effect size.	Practice (2 pts maximum): 2	Outcome measures (2 pts maximum): 2;	Results/findings (3 pts max.): 1; Appropriateness of statistical analysis - Different recording methods pre and post; effect size estimate modeled
Sandler SG, Langeberg A, and Dohnalek L. - 2005 - Developmental Biology - Georgetown University Hospital (multiple departments), Washington DC, USA - Funding: Partially from the Greenspring Financial Insurance Limited (GFIL)	- Design: Non-comparative - Facility: Georgetown Univ. Hospital, Washington, DC; 609-bed, not-for-profit, acute care teaching/research facility. - Study Setting: 18-bed hematology-oncology-bone marrow transplant unit - Time Period: 10/02- no end date provided - Sample: >125 tests, all blood samples and blood components for transfusions. -Comparator: Not reported - Study bias: No time period and number of patients represented by transfusions reported. Focus on nurses who transfuse infrequently.	- Description: Barcoding system for transfusion linking patients’ wristbands with blood component labels. Consists of the hand-held PC/bar-code scanner with radio frequency port to a portable printer. Duration: 10/02 - ?(no end date) - Training: provided during 1- hour session including written and instruction review on how to use the system. - Staff: Nurses - Cost: not reported	- Description: (1) Positive Identification rate Percentage of patients, blood samples and blood components for transfusion positively and accurately identified (2) Number of correctly labeled samples - labels for blood sample tubes & certification forms legible with complete information - Recording Method: Electronic medical record	- Non-comparative time series: - Findings/Effect Size: (1) “All (100%) patients, blood samples, and blood components for transfusion were positively and accurately identified.” (2) “All (100%) bar-code-labeled blood sample tubes and certification forms were legible with complete information. - Stat. Significance/Test(s): None - Results/conclusions biases: Purpose to focus on nurses who transfuse blood infrequently, yet no data presented for these results (suggest that these nurses perform more poorly than nurses who transfuse frequently). Results focused on subjective ratings.
Quality Rating: 2 (Poor) (10 point maximum) Effect Size Magnitude Rating: N/A (Relevance: Direct)	Study (3 pts maximum): 0; - Study Setting: Sufficiently distinctive that results unlikely generalizable - Bone marrow transplant unit transfusions (−2) - Potential Study Bias: Study time period and sample selection may introduce bias affecting results - Study time period not reported (−1)	Practice (2 pts maximum): 1; - Adequacy of practice description: Important aspect likely to critically affect implementation of the practice is not well described - No practice duration specified	Outcome measures (2 pts maximum): 1; Recording method is not adequately described.	Results/findings (3 pts maximum): 0 - Sample size: Measurement period not reported; sample size likely too small for a robust estimate of practice impact. - Appropriateness of statistical analysis: Data insufficient to allow effect size calculation(non comparative)
Turner CL, Casband AC, Murphy MF [1] - Yr Published: 2003 - Transfusion - [1] National Blood Service, John Radcliffe Hospital Oxford, UK - Funding: National Blood Service	- Design: Observational study - Facility/Setting Oxford Radcliffe Hospital, 1500 bed teaching hospital, Oxford, UK; Setting: Hematology outpatient clinic (later extended to hematology inpatient ward) - Time Period: Not reported - Sample: First unit RBC transfusions: Pre: 51 (48 blood prescribed) Post: 51. (45 blood prescribed) Sample collection: Pre: 30; Post: 30 - Comparator: Standard system without barcoding (checking and administering blood process of 27 steps; sample collection process 17 steps); manual checking/verification of patient wristband and chart information	- Barcoding system using hand- held computers for scanning barcodes generates barcoded wristbands and labels via portable printer for crossmatch with blood administration process (16 steps) and sample collection and verification process (8 steps) at bedside. - Duration: Not provided - Training: Education/training on transfusion safety and use of the barcode system was provided to staff - Staff: Phlebotomists, blood bank receptionists, IT, blood bank (Note: Staff preferred the new technology once familiar with it) - Cost: Initial equipment/support ~ $1.2 million (US$ 2003)	- Description: Blood administration % correct performance of blood pack bedside checks (1) Patient ID (name, DOB, sex, hospital #). (2) Cross ref. of blood group, unit #, compatibility label, expiration date, prescription & transfusion report requirements (3) Sample collection: % tubes labeled immediately with hospital #, date, sex, name, DOB - Recording Method: Audits/direct observations	- Pretest-Posttest: - Findings/Effect Size: (1) Blood admin. patient ID check: Pre: 100% (51 /51) Post: 100% (51 /51) 0% improvement (2) Blood admin. cross reference check: Pre: 9.8% ( 5/51) Post: 41.2% (21 /51) 30.4% improvement p-value : 0.0005 (3) Sample collection labels - patient ID -Pre: 50% (15/30) Post: 100% (30/30) 50% improvement (p-value: <0.0001) - Stat. Significance/Test(s): Exact tests of independent proportions -Biases: Study period not reported, small sample, education and training possible confounders
Quality Rating: 4 ( Poor) (10 point maximum) Effect Size Magnitude Rating: N/A (Relevance: Indirect)	Study (3 pts maximum): 1; - Study Setting: Sufficiently distinctive that results may not be generalizable – hematology outpatient transfusions - Potential study bias: Time period and sample selection	Practice (2 pts maximum): 1; - Adequacy of practice description: Important aspect likely to critically affect implementation of the practice is not well described - No practice duration specified	Outcome measures (2 pts maximum): 1; - Face validity: Process outcomes lack correspondence to evidence review PSID error rate outcome	Results/findings (3 pts maximum): 1; - Sample size: Measurement period not reported; sample size likely too small for robust estimate. - Uncontrolled deviations: Results not clearly attributable to practice - training may have an impact
Zarbo RJ, Tuthill JM, D’Angelo R, Varney R, Mahar B, Neuman C, Ormsby A. - 2009 - Am J Clin Pathol - Department of Pathology, Henry Ford Hospital, Detroit, MI. - Funding: Not reported	- Design: Before-after - Facility: Henry Ford Hospital, Detroit, MI; anatomic pathology volumes over 80,000 surgical pathology lab cases/year. - Study Setting: Surgical Pathology lab gross room - Time Period: Two 3-week periods: Pre: 7/06; Post: 8/07 - Sample: Surgical cases/accessions (specimen containers): Pre: 2,694; Post: 2,877 Specimen parts: Pre: 4,413; Post: 4,725 Tissue cassettes: Pre: 8,776; Post: 9,167 Histology slides: Pre: 14,270; Post:17,927 - Comparator: Simple-logic, bar-coded slide label only (2006); specimen accessioning and processing completed by manual entry of information and hand written labels on specimen cassettes and slides	- Barcoding system and process redesign to standardize workflow using a complex- logic, bar-coded pathway tying together 4 work cells to provide computer-readable encoding for identification of parts, and accession, gross dissection, histology/microtomy, and pathology sign-out stations. Also includes manual quality control checks at each station (2007 implementation). No electronic order entry or interface. - Duration: 3 weeks - July 2007 Training: - Group education session, ensuring all staff mem- bers were in unison on the goals and time frame of the data collection and how to use the visual data display - Staff: Surgical pathology, histology and informatics staff - Cost: Not reported	- Description: Patient specimen identification (PSID) error rates (1) Surgical cases (2) Specimen parts – mismatch between pathology requisition and patient information (3) tissue cassettes – mismatch between cassette ID and lab tag information (4) histology slide labels - Recording Method: Data collected, recorded and defects categorized by 59 surgical pathology personnel ( 21 senior staff and 38 technical staff), using a visual data display collection tool	- Pretest-Posttest - Findings/Effect Size: PSID error rates (1) Surgical cases/accessions (specimen containers): Pre: 1.67% (45/2,694) Post: 0.63% (18/2,877) Absolute decrease: 1.0% Relative decrease 62.3%; p-value: <.001 ➢ OR = 2.68 (CI: 1.55–4.63) (2) Specimen parts Pre: 0.23% (10/4,413) Post: 0.38% (11/4,725) 0% reduction - not stat. significant (3) Tissue cassettes Pre: 0.057% (5/8,776) Post : 0.055% (5/9,167) 3.5% reduction; not stat. significant (4) Histology slide labels Pre: 0.21%, (30/14,270) Post : 0.01% ( 2/17,927) 95.2% reduction; p-value <.001 - Stat. Significance/Test(s): χ2 tests (Fisher exact test adjusted for small counts and Mantel- Haenszel test) to 2 data sets
Quality Rating: 9 (Good) (10 point maximum) Effect Size Magnitude Rating: Substantial (Relevance: Direct)	Study (3 pts maximum): 2; - Study Setting: Sufficiently distinctive that results may not be generalizable to other settings/specimens – Surg. path. workflow redesign	Practice (2 pts maximum): 2	Outcome measures (2 pts maximum): 2	Results/findings (3 pts maximum): 3