Narrow Results Clear All
Search results for "Risk Managers"
Cases & Commentaries
- Web M&M
Dorothy Dougherty, RN; November 2010
A hospitalized 2-month-old infant is fed breast milk from another infant's mother after the wrong bottle is pulled from the ward's refrigerator.
Journal Article > Study
Hain PD, Joers B, Rush M, et al. Qual Saf Health Care. 2010;19:244-247.
Patient misidentification errors are surprisingly common, as demonstrated in studies in the inpatient and emergency department settings. In this study, a children's hospital conducted a continuous quality improvement intervention to reduce misidentification errors. Interventions—many of which were suggested by staff—included wristband standardization and a "stop-the-line" policy if a misidentification error was suspected. The project resulted in a significant and sustained reduction in these errors. An AHRQ WebM&M commentary discusses a near miss that occurred due to a misidentification error in the labeling of phlebotomy specimens.