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Cases & Commentaries
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- Web M&M
Allan S. Frankel, MD; Kathryn C. Adair, PhD; and J. Bryan Sexton, PhD; June 2019
A proceduralist went to perform ultrasound and thoracentesis on an elderly man admitted to the medicine service with bilateral pleural effusions. Unfortunately, he scanned the wrong patient (the patient had the same last name and was in the room next door). When the patient care assistant notified the physician of the error, he proceeded to scan the correct patient. He later nominated the assistant for a Stand Up for Safety Award.
Journal Article > Commentary
McDonald CJ. Ann Intern Med. 2006;144:510-516.
This case study shares the events of a near miss when a patient almost received a fatal dose of insulin in response to another patient's reported hyperglycemia. Ironically, the root cause of the problem involved a new bar-coding system to prevent errors in patient identification. The authors discuss the case in detail and advise caution in the implementation of new technology (eg, computerized provider order entry), which may solve safety issues but create the opportunity for others. This article is part of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.
Journal Article > Study
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Although instances of wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) have been widely publicized, the true incidence of such errors remains unclear. A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in the outpatient setting or in ambulatory surgery as well. In this study, the authors reviewed four databases to determine the incidence of all WSPEs, including procedures performed outside the operating room. Data from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur yearly, with many occurring during outpatient procedures. The authors argue that all WSPEs should be considered preventable, and recommend reporting and prevention standards for reducing such errors.
PA-PSRS Patient Saf Advis. June 2007;4:29, 32-45.
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggestions to reduce this type of error.