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.
Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.
A patient was mistakenly administered intravenous fentanyl which was leftover from a previous patient and not immediately wasted.
Children's Hospital Colorado requires clinicians in all inpatient and outpatient facilities to confirm any order entered into its computerized order entry system through a popup verification screen that includes a prominent photograph of the patient, along with other key information such as age and gender. The goal is to capture the clinician's attention and force him or her to verify that the order has been entered into the correct patient's chart.