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Patient identification errors: the detective in the laboratory.

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Salinas M, López-Garrigós M, Lillo R, et al. Clin Biochem. 2013;46:1767-9.

Although electronic test ordering resulted in fewer patient identification errors in a clinical laboratory, significant variability in error rates between centers remained, emphasizing the continued effect of human behavior on interventions.

Are You Mrs. A? An Issue of Identification Over Telephone

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October 1, 2013

After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

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Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.

This study found a significant reduction in mislabeled blood specimens after implementing barcode technology.

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.

This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.

ISMP medication error report analysis.

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Cohen MC.

This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of medication error reports addresses examples of unclear dose preparation instructions, potential insulin storage mix ups, and drug name confusion.

Medication Safety and Hospital Referrals: A Report by the Health and Disability Commissioner.

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Paterson R. Auckland, NZ; Office of the Health and Disability Commissioner: April 2007.

This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of medication error reports provides examples of problems related to abbreviations, electronic prescribing, and communication of critical lab values.

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