Wrong-site, wrong-procedure, and wrong-patient errors (WSPEs) are serious adverse events. This retrospective analysis of medical liability claims data examined the incidence of WSPEs in France between 2007 and 2017. During this ten-year period, WSPEs accounted for 0.4% of all claims. Procedures on the wrong organ were most common (44%), followed by wrong side (39%), wrong person (13%) and wrong procedure (4%). The researchers found that the average number of WSPEs decreased after implementation of a surgical checklist.

Transfusion errors can have serious consequences. This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient, and outpatient. Results show emergency department WBIT errors were significantly higher in emergency departments, and that electronic positive patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient or outpatient wards.

Patient misidentification errors can result in serious patient harm. The authors reviewed over 1.3 million electronic orders for inpatients at one New York hospital between 2016 and 2018 and found that wrong-patient order errors occurred more frequently on obstetric units than medical-surgical units. Medication errors were the largest source of order errors and commonly involved antibiotics and opioid and non-opioid analgesics.

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.  

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.

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-site, wrong-procedure, and wrong-patient errors are surgical never events. This commentary describes a structured communication practice requirement designed to address the problem. The author outlines elements of the protocol and reviews implementation strategies.

Wrong-patient errors are considered to be never events. Newborns are assigned temporary names if they don't have a name immediately after birth, and this may increase the rates of wrong-patient errors. The need for first and last names in electronic health records has led to a generic first name convention of "Babygirl" or "Babyboy," which is in use in more than 80% of neonatal intensive care units in the United States. This pre-post study found that implementing specific first names that incorporated the mother's name reduced the incidence of wrong-patient errors by 36% compared to the generic naming. These errors are rare even at baseline, but given the ease of changing the naming convention, this is a pragmatic approach to improving the safety of computerized provider order entry for hospitalized newborns.

While computerized physician order entry is expected to significantly reduce adverse drug events, systems must be implemented thoughtfully to avoid facilitating certain types of errors. A forcing function that mandated correct patient identification resulted in a moderate decrease in wrong-patient prescribing errors within a computerized provider order entry system.

This survey found that physicians chart or write orders in the wrong patient's electronic health record 1.3% of the time, with significant errors for nurses and clinical assistants as well. Respondents believed that a simple solution such as a prominent room number watermark on the screen would prevent such errors, reinforcing the need to be able to augment electronic health record interfaces to improve safety.

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.

More than a decade ago, stories of wrong site surgeries and retained surgical objects galvanized the patient safety movement. Despite public uproar and attention focused on these never events, such incidents continue to occur at alarming rates. This study found that surgeons make these mistakes more than 4000 times per year in the United States. Related malpractice payments have amounted to more than $1.3 billion over the last 20 years. Although this financial burden is substantial, it may pale in comparison to the degree of patient harm resulting from these preventable errors. An incident of wrong-site surgery is discussed in an AHRQ WebM&M commentary.

After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.

This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.

This article describes how an anatomic marking form was developed, discusses its use, and reveals the effect of this process on patient safety.

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

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.

The Case Records of the Massachusetts General Hospital are one of the most hallowed traditions in the medical literature, having been published weekly in the New England Journal of Medicine for more than a century. In contrast to the usual clinical focus, this article discusses a never event—a case of a patient who underwent the wrong surgical procedure. Presented by the surgeon himself, the article details the factors that led to the error, including production pressures, language barriers, and failure to perform a time out, and explores the ramifications of the error for the surgeon, the patient, and the institution.