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May 16, 2022

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.

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

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Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17:e615-e621.

Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.

Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

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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.

Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart

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June 12, 2020

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.

Patient Identification Errors: A Systems Challenge

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January 29, 2020

Multiple patients were admitted to a large tertiary hospital within a 4-week period and experienced patient identification errors. These cases highlight important systems issues contributing to this problem and the consequences of incorrect patient identification.

Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout

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June 1, 2019

A proceduralist went to perform ultrasound and thoracentesis on an elderly man admitted to the medicine service with bilateral pleural effusions. Unfortunately, he scanned the wrong patient (the patient had the same last name and was in the room next door). When the patient care assistant notified the physician of the error, he proceeded to scan the correct patient. He later nominated the assistant for a Stand Up for Safety Award.

Check your medical records for dangerous errors.

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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.

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

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Neily J, Soncrant C, Mills PD, et al. JAMA Netw Open. 2018;1:e185147.

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.

Distinct newborn identification requirement.

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Neonatal patients are at risk for misidentification due to communication challenges and lack of distinguishable features. This report highlights new Joint Commission requirements to reduce errors related to newborn misidentification.

Back to basics: the Universal Protocol.

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Spruce L. AORN J. 2018;107:116-125.

Wrong-site, wrong-procedure, and wrong-patient errors are surgical never events. This commentary describes a structured communication practice requirement designed to address the problem. The author outlines elements of the protocol and reviews implementation strategies.

One Dose, Two Errors

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December 1, 2016

An older woman experienced acute kidney injury after being prescribed a nephrotoxic medication (amphotericin) intended for the ICU patient in the next bed. Caring for both patients, the covering resident entered the medication order for the wrong patient despite a policy requiring infectious disease consultation to prescribe IV amphotericin.

Improvement in detection of wrong-patient errors when radiologists include patient photographs in their interpretation of portable chest radiographs.

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Tridandapani S, Olsen K, Bhatti P. J Digit Imaging. 2015;28:664-70.

This innovative pilot study found significant improvement in radiologists' ability to detect wrong-patient errors when patient photographs were provided with radiographs. The authors advocate for including photographs with portable radiographs to prevent patient mislabeling errors and augment safety.

Consumer Guide to Adverse Health Events.

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St Paul, MN: Minnesota Department of Health; 2015.

This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.

Are You Mrs. A? An Issue of Identification Over Telephone

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October 1, 2013

After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.

Reduction in pediatric identification band errors: a quality collaborative.

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Phillips SC, Saysana M, Worley S, et al. Pediatrics. 2012;129:e1587-93.

A multi-institution collaborative quality improvement project, based on a prior intervention, successfully reduced the incidence of patient misidentification errors.

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.

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Phipps E, Turkel M, Mackenzie ER, et al. Jt Comm J Qual Patient Saf. 2012;38:127-34.

Although ensuring the correct patient receives the appropriate treatment may seem a straightforward task, patient misidentification has resulted in highly publicized errors. The Joint Commission has required standardized processes for avoiding patient misidentification as one of the National Patient Safety Goals. This qualitative study of nurses and residents identified barriers to following appropriate identification practices and characterizes workarounds that providers use to circumvent these perceived barriers. A near miss caused by a patient identification error is discussed in detail in this AHRQ WebM&M commentary.

Cognitive Factors in Health Care.

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Rogers WA, ed. J Exp Psychol Appl. 2011;17(3):191-302.

Articles in this special issue explore the impact of cognition on health care activities such as patient identification, interruptions, and team communication.

Applying the Universal Protocol to improve patient safety in radiology services.

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PA-PSRS Patient Saf Advis. June 2011;8:63-69.

Exploring causes of wrong-site, wrong patient, and wrong procedure errors in radiology, this piece suggests strategies to reduce the incidence of such events.

The ECG Is Not Normal

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June 1, 2011

An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.

Say It Again

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June 1, 2011

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.

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