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Phillips SC, Saysana M, Worley S, Hain PD. Pediatrics. 2012;129:e1587-e1593.
Phillips SC ; Saysana M ; Worley S; et al. Reduction in pediatric identification band errors: a quality collaborative. Pediatrics. 2012; 129: e1587-e1593
A multi-institution collaborative quality improvement project, based on a prior intervention, successfully reduced the incidence of patient misidentification errors.
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Neily J, Soncrant C, Mills PD, et al. JAMA Network Open. 2018;1:e185147.
Check your medical records for dangerous errors.
Graham J. Kaiser Health News. November 21, 2018.
Blood sampling guidelines with focus on patient safety and identification—a review.
Cornes M, Ibarz M, Ivanov H, Grankvist K. Diagnosis (Berl). 2019;6:33-38.
Implementation of a colour-coded universal protocol safety initiative in Guatemala.
Taicher BM, Tew S, Figueroa L, Hernandez F, Ross SS, Rice HE. BMJ Qual Saf. 2018;27:593-599.
Back to basics: the Universal Protocol.
Spruce L. AORN J. 2018;107:116-125.
Chest Tube Complications
Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD
Patient identification and tube labelling—a call for harmonisation.
van Dongen-Lases EC, Cornes MP, Grankvist K, et al; Working Group for Preanalytical Phase (WG-PRE), European Federation of Clinical Chemistry and Laboratory Medicine (EFLM). Clin Chem Lab Med. 2016;54:1141-1145.
Disclosure of medical errors involving gametes and embryos.
Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2016;106:59-63.
Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.
Rebello E, Kee S, Kowalski A, Harun N, Guindani M, Goravanchi F. Health Informatics J. 2016;22:1055-1062.
Patient Safety Essentials for Laboratory Professionals Certificate Program.
Washington, DC: American Association for Clinical Chemistry.
A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital.
Seferian EG, Jamal S, Clark K, et al. BMJ Qual Saf. 2014;23:690-697.
The Final Check: Say it Out Loud.
Plano, TX: Outcome Engenuity; July 2012.
He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.
Phipps E, Turkel M, Mackenzie ER, Urrea C. Jt Comm J Qual Patient Saf. 2012;38:127-134.
Automated identification of extreme-risk events in clinical incident reports.
Ong MS, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:e110-e118.
Decision-making processes used by nurses during intravenous drug preparation and administration.
Dougherty L, Sque M, Crouch R. J Adv Nurs. 2012;68:1302-1311.
Cognitive Factors in Health Care.
Rogers WA, ed. J Exp Psychol Appl. 2011;17:191-302.
Mislabeling of cases, specimens, blocks, and slides: a College of American Pathologists study of 136 institutions.
Nakhleh RE, Idowu MO, Souers RJ, Meier FA, Bekeris LG. Arch Pathol Lab Med. 2011;135:969-974.
Applying the Universal Protocol to improve patient safety in radiology services.
PA-PSRS Patient Saf Advis. June 2011;8:63-69.
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2018.
A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders.
Tarpey K, Schaaf E, Lakhani U, Balcitis J. Jt Comm J Qual Patient Saf. 2010;36:461-467.
The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.
Stahel PF, Mehler PS, Clarke TJ, Varnell J. Patient Saf Surg. 2009;3:14.
The Henry Ford Production System: reduction of surgical pathology in-process misidentification defects by bar code-specified work process standardization.
Zarbo RJ, Tuthill JM, D'Angelo R, et al. Am J Clin Pathol. 2009;131:468-477.
A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.
Francis DL, Prabhakar S, Sanderson SO. Am J Gastroenterol. 2009;104:972-975.
The effectiveness of inking needle core prostate biopsies for preventing patient specimen identification errors: a technique to address Joint Commission patient safety goals in specialty laboratories.
Raff LJ, Engel G, Beck KR, O'Brien AS, Bauer ME. Arch Pathol Lab Med. 2009;133:295-297.
Surgical specimen identification errors: a new measure of quality in surgical care.
Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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