U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
Sign up for a Free Account
R3 Report. June 25, 2018;7:1-2.
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.
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Eric Poon, MD, MPH
Randomized controlled evaluation of an insulin pen storage policy.
Gibbs HG, McLernon T, Call R, et al. Am J Health Syst Pharm. 2017;74:2054-2059.
Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.
Kannampallil TG, Manning JD, Chestek DW, et al. J Am Med Inform Assoc. 2018;25:739-743.
Evaluating serial strategies for preventing wrong-patient orders in the NICU.
Adelman JS, Aschner JL, Schechter CB, et al. Pediatrics. 2017;139:e20162863.
Managing the patient identification crisis in healthcare and laboratory medicine.
Lippi G, Mattiuzzi C, Bovo C, Favaloro EJ. Clin Biochem. 2017;50:562-567.
When doctors get the wrong patient.
Whitman E. Mod Healthc. September 25, 2016.
Evaluation of near-miss wrong-patient events in radiology reports.
Sadigh G, Loehfelm T, Applegate KE, Tridandapani S. AJR Am J Roentgenol. 2015;205:337-343.
Use of temporary names for newborns and associated risks.
Adelman J, Aschner J, Schechter C, et al. Pediatrics. 2015;136:327-333.
Improvement in detection of wrong-patient errors when radiologists include patient photographs in their interpretation of portable chest radiographs.
Tridandapani S, Olsen K, Bhatti P. J Digit Imaging. 2015;28:664-670.
Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.
Adelman JS, Kalkut GE, Schechter CB, et al. J Am Med Inform Assoc. 2013;20:305-310.
The use of patient pictures and verification screens to reduce computerized provider order entry errors.
Hyman D, Laire M, Redmond D, Kaplan DW. Pediatrics. 2012;130:e211-e219.
Preventing wrong site, procedure, and patient events using a common cause analysis.
Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.
Wristbands as aids to reduce misidentification: an ethnographically guided task analysis.
Smith AF, Casey K, Wilson J, Fischbacher-Smith D. Int J Qual Health Care. 2011;23:590-599.
Incorrect surgical procedures within and outside of the operating room: a follow-up report.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.
Minimizing electronic health record patient–note mismatches.
Wilcox AB, Chen YH, Hripcsak G. J Am Med Inform Assoc. 2011;18:511-514.
Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.
ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.
Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.
Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.
Wrong-patient, wrong-site procedures persist despite safety protocol.
O'Reilly KB. American Medical News; Nov. 1, 2010.
Specimen labeling errors in surgical pathology: an 18-month experience.
Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.
Patient misidentifications caused by errors in standard barcode technology.
Snyder ML, Carter A, Jenkins K, Fantz CR. Clin Chem. 2010;56:1554-1560.
'Wrong-site' surgical mistakes are rare, preventable.
Stein L. St. Petersburg Times. June 21, 2010.
Is the test result correct? A questionnaire study of blood collection practices in primary health care.
Söderberg J, Wallin O, Grankvist K, Brulin C. J Eval Clin Pract. 2010;16:707-711.
The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.
Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.
An intervention to decrease patient identification band errors in a children's hospital.
Hain PD, Joers B, Rush M, et al. Qual Saf Health Care. 2010;19:244-247.
Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.
Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134:244-255.
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.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364