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This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.   

Patient misidentification errors have the potential for serious patient harm. This study analyzed the processes of care involved in 1,189 wrong-patient events. Most errors occurred during ordering/prescribing (42%). One-quarter of all events reached the patient, most commonly involving inappropriate medication administration or receiving the wrong test or procedure. Errors caught before reaching the patient were primarily attributed to information review by nurses, technicians, or other healthcare staff. The authors recommend several strategies for reducing wrong-patient errors. 
Thomas JJ, Yaster M, Guffey P. Jt Comm J Qual Patient Saf. 2019;46:118-121.
The Universal Protocol was intended to prevent wrong site, wrong procedure and wrong person surgery; however, these errors persist. In an effort to reduce wrong-patient charting and near-miss events involving anesthesia, this study implemented a digital photograph to the pre-anesthesia checklist to prompt visual inspection of the patient’s facial image and verification of their hospital ID bracelet. After implementation, only one instance of wrong-patient charting was documented; however, baseline data was unavailable and thus, it is unknown whether this intervention reduced mischarting error.
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Ferguson C, Hickman L, Macbean C, et al. J Clin Nurs. 2019;28:2365-2368.
Patient misidentification can result in incorrect diagnosis, treatment, and medication administration. This commentary discusses the practice of auditing patient identification wristbands to assess compliance and accuracy. The authors suggest that technological interventions such as smartphone facial recognition and barcode technologies be considered as strategies to avoid patient misidentification.
Quick Safety. October 1, 2018;(45):1-2.
This newsletter article reviews common problems related to patient identification and recommends strategies to ensure verification actions are a part of daily practice. Highlighted suggestions focus on system-level approaches that reduce the potential for incorrect patient data to be entered and proliferate, such as use of frontline confirmation processes and duplicate record monitoring. A WebM&M commentary discussed an incident involving a wrong-patient order in an electronic record system.
Gillespie BM, Harbeck EL, Lavin J, et al. BMJ Open Qual. 2018;7:e000362.
Checklists like the Universal Protocol are a widely accepted strategy for reducing wrong site, wrong procedure, and wrong patient surgeries. The authors describe a campaign that improved checklist participation and completion in an academic hospital in Australia. A PSNet interview with Lucian Leape explored the challenges of achieving robust and universal use of checklists.
Gibbs HG, McLernon T, Call R, et al. Am J Health Syst Pharm. 2017;74:2054-2059.
This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by storing them in locked boxes in patient rooms. Four hospital units had a formal policy change for insulin pen storage, and four units provided education to nurses about insulin pen storage. Researchers found that the policy change was more effective than education in spurring adherence to in-room insulin pen storage guidelines.
An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.
Lippi G, Mattiuzzi C, Bovo C, et al. Clin Biochem. 2017;50:562-567.
Patient identification mistakes associated with diagnostic blood testing can have serious consequences. This commentary recommends several strategies to redesign laboratory processes to reduce risks of specimen misidentification, such as utilizing at least two patient identifiers, providing staff training, and using technologies to track and manage specimens.
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.
Tridandapani S, Ramamurthy S, Provenzale J, et al. Acad Radiol. 2014;21:1038-47.
Similar to a prior smaller study, this study found the inclusion of point-of-care facial photographs obtained with portable chest radiographs increased the identification of wrong-patient errors among a group of 90 academic radiologists.
Seferian EG, Jamal S, Clark K, et al. BMJ Qual Saf. 2014;23:690-7.
This quality improvement initiative used human factors approaches including failure mode and effect analysis, event review, and root cause analysis to successfully reduce the rate of specimen mislabeling in an inpatient setting. This study highlights the importance of re-examining longstanding work processes to augment safety.
Nakhleh RE, Idowu MO, Souers RJ, et al. Arch Pathol Lab Med. 2011;135:969-74.
Looking across 136 institutions, this study quantified mislabeling rates at a cumulative total of 0.11% for cases, specimens, blocks, and slides. The authors reinforce the need for quality monitoring since most errors were caught in the immediate steps following the error.
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.
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.