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Search results for "Active Errors"

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Press Release/Announcement

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

Journal Article > Study

Evaluating serial strategies for preventing wrong-patient orders in the NICU.

Adelman JS, Aschner JL, Schechter CB, et al. Pediatrics. 2017;139:e20162863.

Wrong-patient errors are a well-established risk in the health care setting. Research has shown that providers, often multitasking, may enter notes or medication orders for the wrong patient. A prior study touted point-of-care photographs as a helpful intervention for identifying and preventing wrong-patient errors in a cardiothoracic intensive care unit. However, less is known about wrong-patient errors in the neonatal intensive care unit (NICU) population and ways to prevent them. Researchers analyzed more than 850,000 NICU orders and more than 3.5 million non-NICU orders in pediatric patients over a 7-year period. At baseline, they found that wrong-patient orders occurred more frequently in the NICU population with an odds ratio of 1.56. Interventions included requiring reentry of patient identifiers prior to order entry as well as a new naming system for newborns. Implementation of both led to a 61.1% reduction in wrong-patient errors in the NICU population from baseline. A previous WebM&M commentary highlights a case of wrong-patient identification.

Cases & Commentaries

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

  • Web M&M

Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

Journal Article > Review

Managing the patient identification crisis in healthcare and laboratory medicine.

Lippi G, Mattiuzzi C, Bovo C, Favaloro EJ. Clin Biochem. 2017;50:562-567.

Patient identification mistakes associated with diagnostic blood testing can have serious consequences. This commentary recommends several strategies to redesign laboratory processes to reduce risks of specimen misidentification, such as utilizing at least two patient identifiers, providing staff training, and using technologies to track and manage specimens.

Cases & Commentaries

One Dose, Two Errors

  • Web M&M

Gregory A. Filice, MD; December 2016

An older woman experienced acute kidney injury after being prescribed a nephrotoxic medication (amphotericin) intended for the ICU patient in the next bed. Caring for both patients, the covering resident entered the medication order for the wrong patient despite a policy requiring infectious disease consultation to prescribe IV amphotericin.

Newspaper/Magazine Article

When doctors get the wrong patient.

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.

Cases & Commentaries

Situational Awareness and Patient Safety

  • Web M&M

Jeanne M. Farnan, MD, MHPE; April 2016

A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.

Journal Article > Commentary

Disclosure of medical errors involving gametes and embryos.

Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2016;106:59-63.

This publication advocates for open disclosure of errors in reproductive medicine.

Journal Article > Commentary

Effectiveness of surgical safety checklists in improving patient safety.

Ragusa PS, Bitterman A, Auerbach B, Healy WA III. Orthopedics. 2016;39:e307-310.

Checklists are a popular strategy to improve teamwork and prevent errors. Reviewing the evidence on the use of checklists in surgery, this commentary highlights how the tool and associated time out have reduced some adverse events and helped to manage hierarchy in the operating room.

Cases & Commentaries

New Patient Mistakenly Checked in as Another

  • Web M&M

Robert A. Green, MD, MPH, and Jason Adelman, MD, MS; January 2016

Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.

Journal Article > Study

Use of temporary names for newborns and associated risks.

  • Classic

Adelman J, Aschner J, Schechter C, et al. Pediatrics. 2015;136:327-333.

Wrong-patient errors are considered to be never events. Newborns are assigned temporary names if they don't have a name immediately after birth, and this may increase the rates of wrong-patient errors. The need for first and last names in electronic health records has led to a generic first name convention of "Babygirl" or "Babyboy," which is in use in more than 80% of neonatal intensive care units in the United States. This pre-post study found that implementing specific first names that incorporated the mother's name reduced the incidence of wrong-patient errors by 36% compared to the generic naming. These errors are rare even at baseline, but given the ease of changing the naming convention, this is a pragmatic approach to improving the safety of computerized provider order entry for hospitalized newborns.

Journal Article > Review

Patient safety in dermatologic surgery part 1. Patient safety in procedural dermatology part 2.

Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. J Am Acad Dermatol. 2015;73:1-26.

This two-part review series explores patient safety in dermatologic practice. The first article discusses safety issues and error reduction tactics in dermatologic surgical practice, highlighting the importance of correct site identification. The second review examines safety problems associated with cosmetic procedures, including complications around nonphysician operators in this field.

Journal Article > Study

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.

This innovative pilot study found significant improvement in radiologists' ability to detect wrong-patient errors when patient photographs were provided with radiographs. The authors advocate for including photographs with portable radiographs to prevent patient mislabeling errors and augment safety.

Journal Article > Study

Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification.

Nijhawan RI, Lee EH, Nehal KS. Dermatol Surg. 2015;41:499-504.

This study found that encouraging patients to take skin biopsy selfies on smartphones may help patients and physicians more accurately identify the correct biopsy site for subsequent surgical excision, potentially avoiding wrong-site surgeries.

Journal Article > Study

'Sorry, I meant the patient's left side': impact of distraction on left-right discrimination.

McKinley J, Dempster M, Gormley GJ. Med Educ. 2015;49:427-435.

Wrong-side procedures still occur at alarming rates, particularly outside of the operating room. This study exposed medical students to various types of distractions and measured their ability to distinguish a person's left from right side from different perspectives. Cognitive distractions had a bigger negative impact than ambient ward noise on the students' performance.

Journal Article > Study

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.

Hudson ME, Chelly JE, Lichter JR. Br J Anaesth. 2015;114:818-824.

Wrong-surgery errors continue to occur despite their status as never events. This study found that wrong-site block occurred at a rate of about 1 per 10,000 nerve blocks, and these persisted even after implementation of time out procedures. The authors highlight the need to develop interventions to prevent these events.

Newspaper/Magazine Article

Wrong-site orthopedic operations on the extremities: the Pennsylvania experience.

Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.

Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.

Cases & Commentaries

Two Wrongs Don't Make a Right (Kidney)

  • Spotlight Case
  • CME/CEU
  • Web M&M

by John G. DeVine, MD; March 2015

A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.

Journal Article > Review

Applying fault tree analysis to the prevention of wrong-site surgery.

Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C IV, Mehrotra S. J Surg Res. 2015;193:88-94.

This systematic review investigated root causes of wrong-site surgery and identified three vulnerabilities: transcription errors prior to surgery, intraoperative verification failures, and omitting steps in the verification process. The Universal Protocol does not mitigate these vulnerabilities, suggesting that further interventions are required to prevent wrong-site surgeries. A recent AHRQ WebM&M commentary provides an overview of wrong-site surgery and best practices to prevent it.

Journal Article > Study

Intercepting wrong-patient orders in a computerized provider order entry system.

Green RA, Hripcsak G, Salmasian H, et al. Ann Emerg Med. 2015;65:679-686.

While computerized physician order entry is expected to significantly reduce adverse drug events, systems must be implemented thoughtfully to avoid facilitating certain types of errors. A forcing function that mandated correct patient identification resulted in a moderate decrease in wrong-patient prescribing errors within a computerized provider order entry system.

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