Following a sentinel wrong-patient event, a multidisciplinary quality improvement team worked to enhance the safety of blood transfusion. The authors report significant improvement in protocol adherence following institution of barcoding and auditing via the electronic health record.

The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.

Wrong-patient errors are a well-established risk in the health care setting. Research has shown that providers, often multitasking, may enter notes or medication orders for the wrong patient. A prior study touted point-of-care photographs as a helpful intervention for identifying and preventing wrong-patient errors in a cardiothoracic intensive care unit. However, less is known about wrong-patient errors in the neonatal intensive care unit (NICU) population and ways to prevent them. Researchers analyzed more than 850,000 NICU orders and more than 3.5 million non-NICU orders in pediatric patients over a 7-year period. At baseline, they found that wrong-patient orders occurred more frequently in the NICU population with an odds ratio of 1.56. Interventions included requiring reentry of patient identifiers prior to order entry as well as a new naming system for newborns. Implementation of both led to a 61.1% reduction in wrong-patient errors in the NICU population from baseline. A previous WebM&M commentary highlights a case of wrong-patient identification.

Surgical specimen identification errors occur regularly and preventing misidentification errors is a National Patient Safety Goal. This study reports on an effort to develop process measures for monitoring the quality of specimen identification.

Five years after the publication of the Universal Protocol, the authors review the policy and assess unintended consequences, limitations, and recommendations to reduce surgical errors.

Lean thinking strategies were applied to improve workflow and reduce misidentification errors in a surgical pathology laboratory. Following redesign of workflows, the overall misidentification rate reduced by 62% and a 95% reduction in slide misidentification defects. 

This retrospective study reviewed more than 100 cases to characterize common sources of confusion in ophthalmology care. The most common adverse events included wrong lens implants and wrong eye operations, and the authors predict that 85% would have been prevented with use of the Universal Protocol.

The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.

This guidance statement outlines recommendations from the Association of periOperative Registered Nurses (AORN) for developing, implementing, and evaluating safe medication practices in the perioperative environment.