Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.
This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.
Trigger tools are used to detect adverse events; their use has been studied in general oncology patients but not in radiation oncology. In this study, researchers developed an automated radiation oncology-specific trigger tool and found that the tool showed modest sensitivity and specificity at identifying treatment courses with serious or critical near misses.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.