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- Quality Improvement Strategies
- Wrong Patient
Journal Article > Study
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.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.