Narrow Results Clear All
- Communication Improvement 7
- Education and Training 2
- Error Reporting and Analysis 5
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Quality Improvement Strategies 5
- Technologic Approaches 2
- Diagnostic Errors 1
- Identification Errors
- Medical Complications 1
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 5
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Cases & Commentaries
- Web M&M
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
Web Resource > Multi-use Website
Oakbrook Terrace, IL: Joint Commission.
This campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, infection prevention. Each topical package includes infographics, videos, instruction guides, and a podcast.
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
Journal Article > Study
Gray JE, Suresh G, Ursprung R, et al. Pediatrics. 2006;117:e43-e47.
This study demonstrated that more than half of the patients in a single neonatal intensive care unit are at risk for misidentification errors due to similarities in patient names or medical record numbers.
Gray R. Scotland on Sunday. January 8, 2006.
This story discusses the impact of a computer glitch in a system used by more than 80% of general practitioners in Scotland. In addition to physician notes being inadvertently attached to the wrong patient's medical record, reports suggest that some patients actually received incorrect prescriptions due to printing errors caused by the system.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Bramson K, Mooney T. Providence Journal. August 18, 2006.
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation.
Journal Article > Commentary
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
Szabo L. USA Today. February 5, 2007.
This article suggests ways for patients to play a proactive and informed role in their own safe care. A video entitled "Things you should know before entering a hospital" accompanies the article.
Westfall SS, Mascia K. People. October 5, 2009;72:155.
This story discusses an instance of mistakenly implanted embryos and the impact of the error on the two families involved.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Whitman E. Mod Healthc. September 25, 2016.
Misidentification of patients can result in problems such as medication administration delays, blood transfusion mismatches, and wrong-patient surgery. This magazine article reviews recent research on this issue and suggests several system approaches for improvement, including the use of patient photos in electronic health records and standardizing patient identification processes.