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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.

Patient misidentification errors are surprisingly common, as demonstrated in studies in the inpatient and emergency department settings. In this study, a children's hospital conducted a continuous quality improvement intervention to reduce misidentification errors. Interventions—many of which were suggested by staff—included wristband standardization and a "stop-the-line" policy if a misidentification error was suspected. The project resulted in a significant and sustained reduction in these errors. An AHRQ WebM&M commentary discusses a near miss that occurred due to a misidentification error in the labeling of phlebotomy specimens.

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