Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.

Kristen L. W Webster; Reetta Stikes; Lisa Bunnell; Amanda Gardner; Sara Petruska

Commentary

Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.

August 18, 2021

Webster KLW, Stikes R, Bunnell L, et al. J Perinat Neonatal Nurs. 2021;35(3):258-265.

View more articles from the same authors.

Infant misidentification or abduction are considered never events. This article discusses the results of a failure mode and effects analysis to identify and eliminate or reduce the risk of infant misidentification or abduction. Twenty-eight failure modes were identified; the highest-ranked items involved concerns for uninvited individuals on the unit, interactions with child-protective services, alarm fatigue, and inadequate identification checks of the infants with mothers.

PubMed citation

Available at

Related Resources From the Same Author(s)

Handoffs and teamwork: a framework for care transition communication.

June 29, 2022

Perinatal patient safety and quality.

July 6, 2011

Failure to rescue in neonatal care.

September 7, 2011

Best practices in medication administration: preventing adverse drug events in perinatal settings.

March 7, 2007

Patient safety in the NICU: a comprehensive review.

July 6, 2011

Bringing change-of-shift report to the bedside: a patient- and family-centered approach.

December 1, 2010

Perceptions of nurses who are second victims in a hospital setting.

December 22, 2021

Preventing patient positioning injuries in the nonoperating room setting.

August 24, 2022

Adverse events associated with home blood transfusion: a retrospective cohort study.

May 12, 2021

Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study.

August 10, 2022

Differences in hospitals' workplace violence incident reporting practices: a mixed methods study.

May 18, 2022

TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate critical versus end-of-life care?

September 15, 2021

Patient Safety and Quality.

March 3, 2010

Postdischarge adverse events among neonates admitted to the neonatal intensive care unit.

September 7, 2022

Evaluating patient identification practices during intrahospital transfers: a human factors approach.

March 29, 2023

May 26, 2021

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

A mixed methods evaluation of medication reconciliation in the primary care setting.

March 2, 2022

Latent safety threats and countermeasures in the operating theater: a national in situ simulation-based observational study.

February 23, 2022

Human factors analysis of latent safety threats in a pediatric critical care unit.

May 18, 2022

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.

September 29, 2021

A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients.

March 2, 2022

Economic evaluation of quality improvement interventions to prevent catheter-associated urinary tract infections in the hospital setting: a systematic review.

March 30, 2022

Nurse-reported bullying and documented adverse patient events: an exploratory study in a US Hospital.

June 24, 2020

Application of human factors methods to understand missed follow-up of abnormal test results.

November 11, 2020

Emotion and coping in the aftermath of medical error: a cross-country exploration.

March 4, 2015

Association of clinical nursing work environment with quality and safety in maternity care in the United States.

November 11, 2020

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

September 1, 2021

Improving infusion pump safety through usability testing.

May 31, 2017

Comparative performance of pediatric weight estimation techniques: a human factor errors analysis.

November 1, 2017

Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators.

July 28, 2021

Improving hospital infant safe sleep compliance by using safety prevention bundle methodology.

February 2, 2022

Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures.

September 21, 2011

Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis.

July 7, 2021

Medication reconciliation during hospitalization and in hospital-home interface: an observational retrospective study.

April 7, 2021

Fall prevention with the Smart Socks System reduces hospital fall rates.

September 7, 2022

Hospital cultural competency and attributes of patient safety culture: a study of U.S. hospitals.

November 17, 2021

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists.

October 13, 2021

Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths.

March 24, 2021

Nursing interventions to reduce medication errors in paediatrics and neonates: systematic review and meta-analysis.

December 8, 2021

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

Second victims among baccalaureate nursing students in the aftermath of a patient safety incident: an exploratory cross-sectional study.

September 22, 2021

Nurses as 'second victims' to their patients' suicidal attempts: a mixed-method study.

June 30, 2021

Barriers and facilitators to incident reporting in mental healthcare settings: a qualitative study.

November 13, 2019

Hospital at Home: setting a regulatory course to ensure safe, high-quality care.

February 2, 2022

Clinical Issues Series.

May 31, 2006

Psychological safety and error reporting within Veterans Health Administration hospitals.

March 4, 2015

Human Factors In Healthcare.

March 23, 2022

To what extent is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations? A descriptive study.

February 16, 2022

The impact of the built environment on patient falls in hospital rooms: an integrative review.

June 16, 2021

Enhancing healthcare process design with human factors engineering and reliability science, part 1: setting the context.

January 16, 2008

The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care-a systematic review.

March 8, 2023

Patients' willingness and ability to identify and respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data.

July 27, 2022

Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement.

April 28, 2021

Adverse events and burnout: the moderating effects of workgroup identification and safety climate.

July 1, 2020

Drug-drug interactions and prescription appropriateness at hospital discharge: experience with COVID-19 patients.

April 21, 2021

Reporting of hazards and near-misses in the ambulatory care setting.

October 19, 2011

Implementation of the SBAR communication technique in a tertiary center.

October 29, 2008

Prevention of failure to rescue in obstetric patients: a realist review.

November 10, 2021

Medication errors' causes analysis in home care setting: a systematic review.

February 9, 2022

The work of nurses to provide good and safe services to children receiving hospital-at-home: a qualitative interview study from the perspectives of hospital nurses and physicians.

October 20, 2021

Implicit racial bias in pediatric orthopaedic surgery.

June 15, 2022

Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies.

September 9, 2020

Medication errors at hospital admission and discharge: risk factors and impact of medication reconciliation process to improve healthcare.

October 20, 2021

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

Transmission of community- and hospital-acquired SARS-CoV-2 in hospital settings in the UK: a cohort study.

November 10, 2021

Call to action: addressing pediatric fall safety in ambulatory environments.

December 1, 2021

Effect of medication reconciliation at hospital admission on 30-day returns to hospital: a randomized clinical trial.

October 6, 2021

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings.

June 16, 2021

Disaster ergonomics: human factors in COVID-19 pandemic emergency management.

August 19, 2020

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement.

June 1, 2022

Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients.

April 27, 2022

Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence.

June 2, 2021

Association between surgeon technical skills and patient outcomes.

September 9, 2020

Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.

June 29, 2022

Understanding the cognitive work of nursing in the acute care environment.

October 19, 2005

Safety in pediatric hospice and palliative care: a qualitative study.

September 23, 2020

Validation of the second victim experience and support tool-revised in the neonatal intensive care unit.

January 12, 2022

Finding diagnostic errors in children admitted to the PICU.

February 8, 2017

Radio frequency identification applications in hospital environments.

August 16, 2006

Automated identification of diagnostic labelling errors in medicine.

June 8, 2022

Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods study.

October 13, 2021

Psychometric properties of the perinatal missed care survey and missed care during labor and birth.

January 19, 2022

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

October 20, 2021

Using potentially preventable severe maternal morbidity to monitor hospital performance.

February 8, 2023

Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient safety: literature review.

August 18, 2021

Just Culture, Medication Error Prevention, and Second Victim Support: a Better Prescription for Preparing Nursing Students for Practices.

June 2, 2021

Patient harm during COVID-19 pandemic: using a human factors lens to promote patient and workforce safety.

December 23, 2020

Risk factors for clinically relevant deviations in patients' medication lists reported by patients in personal health records: a prospective cohort study in a hospital setting.

March 2, 2022

How and when organization identification promotes safety voice among healthcare professionals.

October 6, 2021

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children.

June 30, 2021

An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.

December 8, 2021

Gender bias in risk management reports involving physicians in training - a retrospective qualitative study.

November 9, 2022

Exploring nurses' attitudes, skills, and beliefs of medication safety practices.

August 24, 2022

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

October 20, 2021

Effective strategies to increase reporting of medication errors in hospitals.

January 25, 2006

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.

June 8, 2022

Perceptual gaps between clinicians and technologists on health information technology-related errors in hospitals: observational study.

March 3, 2021

Related Resources

Causes for medical errors in obstetrics and gynaecology.

June 28, 2023

A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line.

June 21, 2023

Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene.

June 14, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs survey.

April 12, 2023

A customized triggers program: a children's hospital's experience in improving trigger usability.

February 8, 2023

Society for Maternal-Fetal Medicine Special Statement: telemedicine in obstetrics-quality and safety considerations.

February 1, 2023

Examination of maternal near-miss experiences in the hospital setting among Black women in the United States.

December 14, 2022

Patient Safety Innovations

Journal Article

Study

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

November 16, 2022

A longitudinal study of a multifaceted intervention to reduce newborn falls while preserving rooming-in on a mother-baby unit.

October 5, 2022

Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities.

August 10, 2022

Human factors analysis of latent safety threats in a pediatric critical care unit.

May 18, 2022

Care transition of trauma patients: processes with articulation work before and after handoff.

February 16, 2022

Validation of the second victim experience and support tool-revised in the neonatal intensive care unit.

January 12, 2022

Safety, Equity and Engagement in Maternity Services.

January 12, 2022

Communication regarding adverse neonatal birth events: experiences of parents and clinicians.

December 1, 2021

Maternal mortality: near-miss events in middle-income countries, a systematic review.

November 24, 2021

Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review.

September 29, 2021

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

September 22, 2021

Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11.

September 1, 2021

A comprehensive departmental care review model: requirements, structure, and flow.

June 30, 2021

Quality of life after maternal near miss: a systematic review.

June 2, 2021

WebM&M Cases

An Inadvertent Bolus of Norepinephrine.

May 26, 2021

Maintaining maternal-newborn safety during the COVID-19 pandemic.

May 26, 2021

Racial/ethnic inequities in pregnancy-related morbidity and mortality.

March 10, 2021

How to do no harm: empowering local leaders to make care safer in low-resource settings.

March 3, 2021

First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality.

March 3, 2021

Society for Maternal-Fetal Medicine Special Statement: a maternal transport briefing form and checklist.

December 23, 2020

Dispensing Errors.

December 16, 2020

WebM&M Cases

Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.

November 25, 2020

See More About The Topic

Labor and Delivery

Quality and Safety Professionals

Pediatrics

Near Miss

Human Factors Engineering

Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site