Misidentification Error Research Articles

The role of critical incident monitoring in detection and prevention of human breast milk confusions

Feeding a mother's expressed breast milk to the wrong infant is a well-known misidentification error in neonatal intermediate care units (NICU) with potential harmful consequences for the neonate. In this study, we aimed to analyze the role of critical incident monitoring on detection and prevention of human breast milk confusions. The critical incident monitoring made us aware of this misidentification error on our NICU. Despite the implementation of system changes to make breast milk application clearer and safer, we failed to reduce the incidence of breast milk confusions.

LAPAROSCOPIC BILE DUCT INJURY: UNDERSTANDING THE PSYCHOLOGY AND HEURISTICS OF THE ERROR

Bile duct injury is an important unsolved problem of laparoscopic cholecystectomy, occurring with unacceptable frequency even in the hands of experienced surgeons. This suggests that a systemic predisposition to the injury is intrinsic to cholecystectomy and indicates that an analysis of the psychology and heuristics of surgical decision-making in relation to duct identification may be a guide to prevention. Review of published reports on laparoscopic bile duct injury from 1997 to 2007 was carried out. An analysis was also carried out of the circumstances of the injuries in 49 patients who had transection of an extrahepatic bile duct and who were referred for reconstruction or were assessed in a medicolegal context. Special emphasis was placed on identifying the possible psychological aspects of duct misidentification. Review of published work showed an emphasis on the technical aspects of correct identification of the cystic duct, with few papers addressing the heuristics and psychology of surgical decision-making during cholecystectomy. Duct misidentification was the cause of injury in 42 out of the 49 reviewed patients (86%). The injury was not recognized at operation in 70% and delay in recognition persisted into the postoperative period in 57%. Underestimation of risk, cue ambiguity and visual misperception ('seeing what you believe') were important factors in misidentification. Delay in recognition of the injury is a feature consistent with cognitive fixation and plan continuation, which help construct and sustain the duct misidentification during the operation and beyond. Changing the 'culture' of cholecystectomy is probably the most effective strategy for preventing laparoscopic bile duct injury, especially if combined with new technical approaches and an understanding of the heuristics and psychology of the duct misidentification error. Training of surgeons for laparoscopic cholecystectomy should emphasize the need to be alert for cues that the incorrect duct is being dissected or that a bile duct injury might have occurred. Surgeons may also be trained to accept the need for plan modification, to seek cues that refute a given hypothesis and to apply 'stopping rules' for modifying or converting the operation.

Evaluation of a Computer-assisted Photograph-matching System to Monitor Naturally Marked Harbor Seals at Tugidak Island, Alaska

Monitoring the dynamics and status of populations of harbor seals (Phoca vitulina richardii) requires efficient methods for estimating population parameters from mark-resight data. We used a test set of photographs from 182 individuals identified by flipper tags, scars, or unique pelage markings to test whether individuals could be identified accurately by their ventral pelage markings; to document efficiency and misidentification error rate associated with a computer-assisted photograph-matching system; and to test for bias in mark-recapture survival estimates resulting from misidentification errors. Pelage patterns of seals that were not of dark-intermediate or intermediate color phase were unique and stable from birth until 6–8 years, and from year to year as adults. The computer-assisted system greatly improved efficiency of photograph matching: 93.3% of good photographs and 69.9% of all photographs ranked 1st, and 95.2% of good photographs ranked in the top 0.3% of the ordered list for visual checking. Additional visual matching error averaged <3.0% for good photographs, and overall misidentification error rate was low at 1.8%, due to the availability of multiple photographs for matching. Inclusion of poor-quality photographs reduced ranking success by ∼20% and increased additional visual matching error up to 20%. Bias in survival estimates was –7.0% for a misidentification rate of 8.8%, but was ≤ 1.1 % for misidentification rates of <2.7%, achieved by restricting data to only good photos. Our study suggests that estimation of misidentification error rate, inclusion of only high-quality photographs, or use of models that account for misidentification error, are required to prevent bias in mark-recapture survival estimates when using data from natural-marking studies.

Procedural errors in antibody identification

Abstract In experimental studies of students and line technologists performing antibody identification procedures, both groups made errors. These errors included, at times, either failing to identify an antibody or misidentifying the specificity(ies). A prospective study was undertaken to identify errors made in a laboratory setting. Errors were classified as 1) failing to follow protocol (procedural error) or 2) arriving at the wrong answer (misidentification error). Over a 1-year period, 1,057 workups were reviewed. There were 41 (3.88%) procedural errors and no misidentification errors. In 25 workups (61% of errors), the selection of cells to rule out underlying alioantibody(ies) was in error. The remaining 16 involved various “slips” (minor mistakes or memory lapses) and clerical errors. Based on an analysis of the probable causes of these errors, potential solutions include 1) developing computer aids to detect “rule-out” errors or missing tests results; 2) providing timely, carefill review of workups before transfusion; and 3) designing better panel layout and cell selection. Immunohematology 1991;1:20–22.

The unconscious transference effect: Are innocent bystanders ever misidentified?

AbstractUnconscious transference refers to an eyewitness's misidentification of an innocent bystander for a criminal perpetrator because of the witness's exposure to the bystander in another context. In a series of five field studies involving 330 retail store clerks and 340 students, five retention intervals from 2 hours to 2 weeks, seven bystander‐perpetrator intervals from 2 minutes to 2 weeks, three line‐up types, two levels of line‐up similarity, four different bystanders and four different targets, with one exception no evidence was obtained that could be interpreted to demonstrate the phenomenon of unconscious transference. That is, the resultsr repeatedly failed to reveal more misidentifications of an innocent bystander by witnesses who had been previously exposed to the bystander than by control evewitnesses who had not. To the contrary, the prior observation of the bystander often served to reduce the frequency of misidentification. In the final experiment the kind of misidentification error referred to as unconscious transference did occur, but only within a particular combination of bystander‐perpetrator similarity and line‐up construction: a combination that, in conjunction with the kind of event used, seems unlikely in real‐world settings. Nevertheless, the inclusion of a familiar face in the line‐ups often altered witnesses' choices in such a way that choosing someone was more likely when the lineup included a familiar face than when it did not. Finally, in contrast to the current explanations of unconscious transference, it is argued that it may not be a sense of familiarity with the bystander that is the basis of misidentifications; rather, it may also include incorrect inferences about the likelihood that the bystander might be the perpetrator.