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This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.
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American Association for Clinical Chemistry; AACC.
This certificate program for laboratory professionals offers six courses aimed at enhancing participants' skills in establishing a just culture, identifying safety hazards, and assessing gaps in processes to reduce risks of specimen management errors.
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Nelson K. Clin Dermatol. 2014;32:542-4.
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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.
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Smith AF, Casey K, Wilson J, et al. Int J Qual Health Care. 2011;23:590-9.
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PA-PSRS Patient Saf Advis. June 2011;8:63-69.
Exploring causes of wrong-site, wrong patient, and wrong procedure errors in radiology, this piece suggests strategies to reduce the incidence of such events.
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Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
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Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.
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Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.
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Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.
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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.
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Cohen MR; Smetzer JL.
This monthly selection of error reports discusses incidents involving incomplete administration of a two-part pediatric vaccine and drug name confusion.
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Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.
This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.
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Cohen MR.
This monthly selection of error reports discusses incidents involving insulin preparation, automated medication cabinet stocking, and medication list filing.
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Cohen MR.
This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.
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Cohen MR.
This monthly selection of error reports shares examples of topical anesthetic error, methotrexate overdose, and child-proof medicine cap dangers.
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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.
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Cohen MR.
This monthly selection of reports discusses an error involving the routing of a printed label in the pharmacy, describes examples of drug name confusion, and highlights an obscure drug concentration change.
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Saufl NM. J Perianesth Nurs. 2009;24:114-8.
