AHRQ Patient Safety Network

The Collection > Wrong Patient

PATIENT SAFETY PRIMERS
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery

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Wrong Patient

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Resource Types

•Journal Article (39)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (9)

•Tools/Toolkit (1)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (20)

•Active Errors (32)

•Latent Errors (8)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (14)

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•Error Reporting and Analysis (16)

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•Technologic Approaches (19)

•Education and Training (9)

Clinical Areas

•Medicine (44)

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Target Audience

•Health Care Providers (38)

•Health Care Executives and Administrators (43)

•Non-Health Care Professionals (20)

•Patients (13)

Setting of Care

•Hospitals (38)

•Ambulatory Care (5)

•Outpatient Surgery (2)

1 - 20 of 56

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NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

STUDY

Wristbands as aids to reduce misidentification: an ethnographically guided task analysis.

Smith AF, Casey K, Wilson J, Fischbacher-Smith D. Int J Qual Health Care. 2011;23:590-599.

STUDY

Specimen labeling errors in surgical pathology: an 18-month experience.

Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

STUDY

Variation in surgical time-out and site marking within pediatric otolaryngology.

Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

STUDY

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

AUDIOVISUAL PRESENTATION

Mix-up: baby nursed by wrong mother.

Cisneros N. ABC-7/KGO-TV. June 10, 2006.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

COMMENTARY

Mistaken Identity

Hall LW. AHRQ WebM&M [serial online]. October 2008.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong-site' surgical mistakes are rare, preventable.

Stein L. St. Petersburg Times. June 21, 2010.

COMMENTARY

EMR Entry Error: Not So Benign

Koppel R. AHRQ WebM&M [serial online]. April 2009.

STUDY

A case of mistaken identity: staff input on patient ID errors.

Ortiz J, Amatucci C. Nurs Manage. April 2009;4:37-41.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:844-847.

BOOK/REPORT

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.

Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.

STUDY

Minimizing electronic health record patient–note mismatches.

Wilcox AB, Chen YH, Hripcsak G. J Am Med Inform Assoc. 2011;18:511-514.

STUDY

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134:244-255.

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