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

Origin/Sponsor

Resource Types

•Journal Article (33)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (6)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (18)

•Active Errors (29)

•Latent Errors (7)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (9)

•Legal and Policy Approaches (3)

•Error Reporting and Analysis (13)

•Communication Improvement (19)

•Human Factors Engineering (12)

•Teamwork (3)

•Logistical Approaches (2)

•Culture of Safety (1)

•Technologic Approaches (16)

•Education and Training (4)

Clinical Areas

•Medicine (34)

•Nursing (2)

•Pharmacy (1)

Target Audience

•Health Care Providers (32)

•Health Care Executives and Administrators (37)

•Non-Health Care Professionals (15)

•Patients (10)

Setting of Care

•Hospitals (30)

•Ambulatory Care (3)

•Outpatient Surgery (2)

1 - 20 of 45

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COMMENTARY classic

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

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

AUDIOVISUAL PRESENTATION

Mix-up: baby nursed by wrong mother.

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

REVIEW

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.

Lippi G, Blanckaert N, Bonini P, et al. Clin Chem Lab Med. 2009;47:143-153.

NEWSPAPER/MAGAZINE ARTICLE

Patients put at risk by NHS computer fault.

Gray R. Scotland on Sunday. January 8, 2006.

STUDY

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

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

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

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.

COMMENTARY

Decreasing patient misidentification before chemotherapy administration.

Spruill A, Eron B, Coghill A, Talbert G. Clin J Oncol Nurs. 2009;13:716-717.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

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.

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

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

STUDY

Minimizing electronic health record patient–note mismatches.

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

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

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.

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

Is the test result correct? A questionnaire study of blood collection practices in primary health care.

Söderberg J, Wallin O, Grankvist K, Brulin C. J Eval Clin Pract. 2010;16:707-711.

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

Barcode technology: its role in increasing the safety of blood transfusion.

Turner CL, Casbard AC, Murphy MF. Transfusion. 2003;43:1200-1209.

MULTI-USE WEBSITE

Medical error.

Wikipedia.

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.

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