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ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.

Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk. 
Rebello E, Kee S, Kowalski A, et al. Health Informatics J. 2016;22:1055-1062.
This electronic audit study examined the incidence of opening and charting in the wrong patient record in the perioperative period. Investigators observed that this error declined over time. They attribute this improvement to time-out procedures and barcoding, both of which facilitate patient identification.
Simons PAM, Houben R, Benders J, et al. Eur J Oncol Nurs. 2014;18:459-65.
This quality improvement study found that adherence to patient safety measures while providing radiation therapy—such as verifying patient identification—increased when work processes were standardized. This finding echoes prior work in applying human factors principles to health care.

ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.

Improper insulin pen use is a persistent problem. This newsletter article reveals the lessons learned from one hospital that implemented best practices including robust education, bar-code scanning, bedside electronic medication administration records, and alerts to prevent incorrect administration but continued to experience errors related to insulin pen use.
Galanter W, Falck S, Burns M, et al. J Am Med Inform Assoc. 2013;20:477-81.
Wrong-patient errors have long been a risk in hospitals. In one seminal case, a patient underwent an invasive procedure intended for another patient with a similar name. In the era of electronic medical records, errors such as entering notes or ordering medications for the wrong patient may occur as a consequence of multitasking. This AHRQ-funded study evaluated the effectiveness of an alert system, which required entry of an appropriate clinical diagnosis, at preventing wrong-patient medication errors in a computerized provider order entry system. Although the system did correctly identify and prevent incorrect prescriptions, 4000 alerts were required to prevent a single error. Other studies have successfully used forcing functions, or simply placing the patient's photograph on the order screen, to prevent wrong-patient errors.
Mehtsun WT, Ibrahim AM, Diener-West M, et al. Surgery. 2013;153:465-472.
More than a decade ago, stories of wrong site surgeries and retained surgical objects galvanized the patient safety movement. Despite public uproar and attention focused on these never events, such incidents continue to occur at alarming rates. This study found that surgeons make these mistakes more than 4000 times per year in the United States. Related malpractice payments have amounted to more than $1.3 billion over the last 20 years. Although this financial burden is substantial, it may pale in comparison to the degree of patient harm resulting from these preventable errors. An incident of wrong-site surgery is discussed in an AHRQ WebM&M commentary.
Nakhleh RE, Idowu MO, Souers RJ, et al. Arch Pathol Lab Med. 2011;135:969-74.
Looking across 136 institutions, this study quantified mislabeling rates at a cumulative total of 0.11% for cases, specimens, blocks, and slides. The authors reinforce the need for quality monitoring since most errors were caught in the immediate steps following the error.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146:1235-9.
This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.
Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-84.
Efforts to prevent wrong-site and wrong-patient surgical errors (WSPEs) initially focused on procedural disciplines and operating room procedures. However, this analysis of WSPEs that were voluntarily reported to a Colorado malpractice insurance company database found that a significant proportion of WSPEs were committed by physicians in non-surgical fields (such as internal medicine). Root cause analysis revealed a number of contributing causes, with diagnostic errors and communication errors the primary culprits. Interestingly, the injured patients did not file a malpractice lawsuit in the vast majority of cases. This study confirms and extends prior research showing that many WSPEs actually occur outside the operating room. The authors call for strict adherence to the Joint Commission Universal Protocol in order to prevent these never events.
Trbovich PL, Pinkney S, Cafazzo JA, et al. Qual Saf Health Care. 2010;19:430-4.
Errors at the administration stage are common for intravenous medications. Programmable or smart infusion pumps are widely used as a means of preventing such errors. However, prior studies have found that smart pumps alone may not significantly reduce errors, as they do not eliminate wrong-patient errors and may be prone to workarounds. This study compared three types of pumps—traditional pumps, smart pumps, and smart pumps combined with bar-code technology—in a simulated inpatient unit. The results indicate that smart pumps may reduce administration errors when combined with bar-coding or when only "hard" (unchangeable) dosing limits are used. Ultimately, creation of a "closed-loop" system that integrates technological solutions to prescription and administration errors represents the optimal solution for eliminating medication errors.