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1 - 15 of 15
Sexton J, Schweber N. ProPublica. October 31, 2019.
Misidentification of patients can cause harm. This news investigation explores an unique case of patient misidentification that resulted in unplanned removal of life support and a subsequent death. The authors identify system failures across the broad health care and criminal justice continuum that contributed to the failure.
Graham J.
Patients can identify errors in their medical records that health care providers may not recognize. This news article highlights the importance of patients correcting seemingly simple mistakes such as name misspellings and phone numbers as these errors can contribute to situations that result in patient harm.
Cohen MR.
This monthly commentary examines risks associated with mismanagement of IV tubing and ports, discusses a recent article regarding unintended consequences of computerized provider order entry (CPOE), and details recent changes to similarly named medications.
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-32.
Wrong site operations are rare and often occur when systems to prevent them fail. This study reviewed existing prevention strategies, such as the Joint Commission's Universal Protocol, to develop a framework for hospitals to assess their wrong site event prevention efforts. The proposed framework asks whether a behaviorally specific policy has been enacted and whether staff understand the policy, and goes on to recommend directly observing the policy being put into practice. The authors advocate standardized interventions utilizing effective methods to measure safety. A previous Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses factors that place patients at risk for wrong site surgery.
Despite persuasion from a surgical resident that her mother's life was in danger, a patient's daughter refuses consent for surgery on her mother. This was wise, since the procedure was intended for a different patient with the same unusual surname.