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Sim MA, Ti LK, Mujumdar S, et al. J Patient Saf. 2022;18:e189-e195.
This article describes the implementation of a hospital-wide patient safety strategy aimed at reducing hospital-wide adverse events at a single large hospital in Singapore. The strategy included establishing interdisciplinary patient safety teams to identify areas of preventable harm, determine root causes, improve departmental accountability, and leveraging simulation training. Over a 7-year period, adverse event rates decreased significantly (as did the incidence of preventable adverse events and the incidence of events resulting in permanent harm, the use of life-sustaining interventions, or death.
Kaufman RM, Dinh A, Cohn CS, et al. Transfusion (Paris). 2019;59:972-980.
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.
Lee ACW, Leung M, So KT. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2005;18:15-23.
This case report evaluates the experience of managing two patients with identical names in the same ward over a five-month period. Although no clinical errors occurred, some records were misplaced. The authors recommend that future safeguards should also address hospital records.