The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
Shaikh U, Natale JAE, Till DA, et al. Pediatr Emerg Care. 2022;38:e283-e286.
Incident reporting systems may be underutilized by medical trainees. This article describes a brief, interactive simulation activity to improve identification and reporting of patient safety hazards among medical students and interns.
Patient misidentification can lead to serious patient safety risks. In this large academic medical center, displaying patient photographs in the electronic health record (EHR) resulted in fewer wrong-patient order entry errors. The authors suggest this may be a simple and cost-effective strategy for reducing wrong-patient errors.
Vanneman MW, Balakrishna A, Lang AL, et al. Anesth Analg. 2020;131:1217-1227.
Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.
Fortman E, Hettinger AZ, Howe JL, et al. J Am Med Inform Asso. 2020.
Physicians from different health systems using two computerized provider order entry (CPOE) systems participated in simulated patient scenarios using eye movement recordings to determine whether the physician looked at patient-identifying information when placing orders. The rate of patient identification overall was 62%, but the rate varied by CPOE system. An expert panel identified three potential reasons for this variation – visual clutter and information density, the number of charts open at any given time, and the importance placed on patient identification verification by institutions.
Rosen DA, Criser AL, Petrone AB, et al. J Patient Saf. 2019;15:e90-e93.
This pre–post study found that color-coded head coverings in the operating room significantly decreased misidentification of attending physicians versus medical students. The authors recommend implementation of this highly feasible solution to enhance proper role identification in the surgical setting.
Patients admitted to the hospital in acute trauma situations may be given an alias for medical record purposes during their hospitalization. This survey of critical care clinicians (attending and trainee physicians, registered nurses, and nurse practitioners) reported that alias use can cause confusion in caring for critically ill patients. The authors recommend avoiding aliases and using actual patient identifiers as soon as possible.
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