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Journal Article > Study
Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.
Hensley NB, Koch CG, Pronovost PJ, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.
Journal Article > Review
Cohen R, Ning S, Yan MTS, Callum J. Transfus Med Rev. 2019:33:78-83.
Inaccurate patient registration can result in information gaps that contribute to delay, misunderstandings, and harm. This review discusses registration errors in the blood transfusion process. The authors discuss how problems can occur during various stages in the transfusion process and result in blood-type discrepancies. They suggest improved reporting of identification mistakes and use of photo identification tools as strategies to prevent patient harm associated with registration errors.
Journal Article > Commentary
The wicked problem of patient misidentification: how could the technological revolution help address patient safety?
Ferguson C, Hickman L, Macbean C, Jackson D. J Clin Nurs. 2019;28:2365-2368.
Patient misidentification can result in incorrect diagnosis, treatment, and medication administration. This commentary discusses the practice of auditing patient identification wristbands to assess compliance and accuracy. The authors suggest that technological interventions such as smartphone facial recognition and barcode technologies be considered as strategies to avoid patient misidentification.
Journal Article > Study
Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.