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.
This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.
Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.
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.