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Search results for "Active Errors"

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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.

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.

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 > 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

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.

Journal Article > Study

A multiobserver study of the effects of including point-of-care patient photographs with portable radiography: a means to detect wrong-patient errors.

Tridandapani S, Ramamurthy S, Provenzale J, Obuchowski NA, Evanoff MG, Bhatti P. Acad Radiol. 2014;21:1038-1047.

Similar to a prior smaller study, this study found the inclusion of point-of-care facial photographs obtained with portable chest radiographs increased the identification of wrong-patient errors among a group of 90 academic radiologists.

Journal Article > Study

An observational study of how patients are identified before medication administrations in medical and surgical wards.

Härkänen M, Kervinen M, Ahonen J, Turunen H, Vehviläinen-Julkunen K. Nurs Health Sci. 2015;17:188-194.

This direct observation study found that verifying patients' identity prior to medication administration, a key patient safety practice, was not routinely employed. Nurses with more experience tended to comply with the identification protocol less, underscoring the challenge of effectively implementing patient safety recommendations.

Cases & Commentaries

Are You Mrs. A? An Issue of Identification Over Telephone

  • Web M&M

Jason S. Adelman, MD, MS; October 2013

After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.

Journal Article > Study

Patient identification errors: the detective in the laboratory.

Salinas M, López-Garrigós M, Lillo R, Gutiérreza M, Lugo J, Leiva-Salinas C. Clin Biochem. 2013;46:1767-1769.

Although electronic test ordering resulted in fewer patient identification errors in a clinical laboratory, significant variability in error rates between centers remained, emphasizing the continued effect of human behavior on interventions.

Journal Article > Study

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.

This study implemented an order verification screen, including the patient's photograph, to reduce the risk that orders will be placed in an unintended patient's electronic health record. In a limited analysis, it appeared to be effective.

Journal Article > Study

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.

After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.

Journal Article > Study

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.

Color-coded wristbands are often used to identify patients and alert providers to specific safety considerations, such as allergies. This study used human factors engineering principles to examine how wristbands were used for safety purposes at two British hospitals.

Journal Article > Study

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.

This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.

Cases & Commentaries

The ECG Is Not Normal

  • Spotlight Case
  • Web M&M

Abigail Zuger, MD; June 2011

An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.

Journal Article > Study

Minimizing electronic health record patient–note mismatches.

Wilcox AB, Chen YH, Hripcsak G. J Am Med Inform Assoc. 2011;18:511-514.

This study noted a 0.3% patient–note mismatch rate (i.e., finding a note in another patient's record), and the authors suggest that the rate depends highly on the user interface design of the system.

Newspaper/Magazine Article

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.

This piece identifies situations in which patient verification errors occur and provides strategies to address them.

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