Dunbar NM, Delaney M, Murphy MF, et al. Transfusion (Paris). 2021;61:2601-2610.
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.
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Obstet Gynecol. 2021;138:229-235.
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.
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.
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.
Hensley NB, Koch CG, Pronovost PJ, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.
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.
Kannampallil TG, Manning JD, Chestek DW, et al. J Am Med Inform Assoc. 2018;25:739-743.
Opening multiple patients' charts in the electronic medical record simultaneously may increase the risk of wrong-patient orders, a known patient safety hazard. Researchers analyzed intercepted wrong-patient medication orders in an emergency department over a 6-year period and found no significant reduction when the maximum number of charts allowed to be open at the same time decreased from 4 to 2. Similarly, there was no significant increase when the maximum number of charts permitted to be open simultaneously increased from 2 to 4.
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.
Adelman JS, Aschner JL, Schechter CB, et al. Pediatrics. 2017;139.
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.
Rebello E, Kee S, Kowalski A, et al. Health Informatics J. 2016;22:1055-1062.
This electronic audit study examined the incidence of opening and charting in the wrong patient record in the perioperative period. Investigators observed that this error declined over time. They attribute this improvement to time-out procedures and barcoding, both of which facilitate patient identification.
Adelman J, Aschner J, Schechter C, et al. Pediatrics. 2015;136:327-333.
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.
Green RA, Hripcsak G, Salmasian H, et al. Ann Emerg Med. 2015;65:679-686.e1.
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.
Yamamoto LG. Hawaii J Med Public Health. 2014;73:322-8.
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.
Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Am J Med Qual. 2013;28:308-14.
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.
Mehtsun WT, Ibrahim AM, Diener-West M, et al. Surgery. 2013;153:465-472.
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.
Mallett R, Conroy M, Saslaw LZ, et al. Am J Med Qual. 2012;27:21-9.
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.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146:1235-9.
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.
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