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 (38)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (8)

•Tools/Toolkit (1)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (19)

•Active Errors (32)

•Latent Errors (7)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (13)

•Legal and Policy Approaches (3)

•Error Reporting and Analysis (15)

•Communication Improvement (20)

•Human Factors Engineering (12)

•Teamwork (4)

•Logistical Approaches (3)

•Culture of Safety (2)

•Technologic Approaches (18)

•Education and Training (9)

Clinical Areas

•Medicine (43)

•Nursing (5)

•Pharmacy (1)

Target Audience

•Health Care Providers (38)

•Health Care Executives and Administrators (43)

•Non-Health Care Professionals (18)

•Patients (13)

Setting of Care

•Hospitals (37)

•Ambulatory Care (5)

•Outpatient Surgery (2)

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STUDY

The use of patient pictures and verification screens to reduce computerized provider order entry errors.

Hyman D, Laire M, Redmond D, Kaplan DW. Pediatrics. 2012;130:e211-e219.

STUDY

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

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

STUDY

Matching identifiers in electronic health records: implications for duplicate records and patient safety.

McCoy AB, Wright A, Kahn MG, Shapiro JS, Bernstam EV, Sittig DF. BMJ Qual Saf. 2013;22:219-224.

STUDY

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.

Adelman JS, Kalkut GE, Schechter CB, et al. J Am Med Inform Assoc. 2013;20:305-310.

STUDY

Minimizing electronic health record patient–note mismatches.

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

COMMENTARY classic

Computerization can create safety hazards: a bar-coding near miss.

McDonald CJ. Ann Intern Med. 2006;144:510-516.

STUDY

An intervention to decrease patient identification band errors in a children's hospital.

Hain PD, Joers B, Rush M, et al. Qual Saf Health Care. 2010;19:244-247.

STUDY

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

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

BOOK/REPORT

Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the US Health Care System.

Hillestad R, Bigelow JH, Chaudhry B, et al. Santa Monica, CA: RAND Corporation; 2008.

STUDY

Application of human error theory in case analysis of wrong procedures.

Duthie EA. J Patient Saf. 2010;6:108-114.

STUDY

Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

Galanter W, Falck S, Burns M, Laragh M, Lambert BL. J Am Med Inform Assoc. 2013;20:477-481.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

COMMENTARY

Mistaken Identity

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

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

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.

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.

STUDY

Medical errors in orthopaedics. Results of an AAOS member survey.

Wong DA, Herndon JH, Canale ST, et al. J Bone Joint Surg Am. 2009;91:547-557.

COMMENTARY classic

The wrong patient.

Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.

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.

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