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Wrong blood in tube (WBIT) errors can be classified as intended patient drawn/wrong label applied or wrong patient/intended label applied. In this international study, errors were divided almost evenly between the two types and most were a combination of protocol violations (e.g. technology not used or not used appropriately) and slips/lapses (e.g., registration errors). Additional contributory factors and recommendations for improvement are also discussed.

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.  

Recent guidelines from the Institute for Safe Medication Practices have warned of the risk of blood-borne disease transmission associated with insulin pen sharing in hospitalized patients and provide recommendations for safe practices.  This paper describes the impact on insulin pen sharing after the implementation of safe practice recommendations (e.g., label redesign, patient-specific bar coding on pens) at a quaternary academic medical center. Institutional efforts resulted in a less frequent pen-sharing events and a decrease in latent errors found during medication drawer audits, such as retained pens after discharge and illegible or missing label. 

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.

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.

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.

Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.

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.

Insulin is a widely used high-risk medication. This quality improvement intervention employed barcode medication administration and a standardized electronic health record–integrated workflow to successfully reduce wrong-patient insulin pen errors. The authors call for widespread implementation of medication safety improvements into electronic health records.

This Delphi study aimed to identify expert consensus on never events in dentistry. The resulting list of 23 events includes medication errors, retained objects, and wrong patient and wrong procedure events across diagnostic and treatment activities and is consistent with existing never events in medicine.

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.

The Universal Protocol is designed to prevent wrong site, wrong procedure, and wrong person surgery. Researchers implemented a color-coded Universal Protocol in a Guatemalan surgery center. Errors decreased after multiple implementation cycles, demonstrating the feasibility of the tool in a developing country.