Narrow Results Clear All
- Communication Improvement 27
- Culture of Safety 8
- Education and Training 8
Error Reporting and Analysis
- Error Reporting 10
- Human Factors Engineering 9
- Legal and Policy Approaches 11
- Logistical Approaches 6
- Quality Improvement Strategies 13
- Teamwork 5
- Technologic Approaches 10
- Transparency and Accountability 1
- Device-related Complications 3
- Discontinuities, Gaps, and Hand-Off Problems 6
- Identification Errors
- Interruptions and distractions 1
- Medical Complications 8
- Medication Safety 10
- Nonsurgical Procedural Complications 2
- Surgical Complications 25
- Transfusion Complications 1
- Medicine 39
- Nursing 1
- Pharmacy 2
- Family Members and Caregivers 2
- Health Care Executives and Administrators 22
Health Care Providers
- Nurses 5
- Non-Health Care Professionals 9
- Patients 28
Search results for "North America"
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
Graham J. Kaiser Health News. November 21, 2018.
Patients can identify errors in their medical records that health care providers may not recognize. This news article highlights the importance of patients correcting seemingly simple mistakes such as name misspellings and phone numbers as these errors can contribute to situations that result in patient harm.
Quick Safety. October 1, 2018;(45):1-2.
This newsletter article reviews common problems related to patient identification and recommends strategies to ensure verification actions are a part of daily practice. Highlighted suggestions focus on system-level approaches that reduce the potential for incorrect patient data to be entered and proliferate, such as use of frontline confirmation processes and duplicate record monitoring. A WebM&M commentary discussed an incident involving a wrong-patient order in an electronic record system.
Arndt RZ. Mod Healthc. July 14, 2018.
Similarities in patient names and clinical situations can result in medical errors. Discussing how digital technologies can exacerbate patient identification problems, this magazine article describes unique elements of information systems that enable mistakes to spread quickly, outlines costs associated with patient mismatches, and recommends improvement strategies such as use of unique patient identifiers. A past WebM&M commentary reviewed an incident involving a patient mix-up.
R3 Report. June 25, 2018;7:1-2.
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.
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.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Improper insulin pen use is a persistent problem. This newsletter article reveals the lessons learned from one hospital that implemented best practices including robust education, bar-code scanning, bedside electronic medication administration records, and alerts to prevent incorrect administration but continued to experience errors related to insulin pen use.
Garcia R. Health Manag Technol. 2013;34:10-11.
This article explains how discrepancies in patient records affect safety and proposes that assigning unique identifiers for patients can improve medical record quality.
Huff C. Trustee Magazine. October 2011.
This article reports on patient safety improvement work in the Veterans Affairs hospital system and describes the implementation of a team training program.
Boodman SG. Washington Post. June 21, 2011:E1.
PA-PSRS Patient Saf Advis. June 2011;8:63-69.
Exploring causes of wrong-site, wrong patient, and wrong procedure errors in radiology, this piece suggests strategies to reduce the incidence of such events.
Rojas-Burke J. The Oregonian. May 25, 2011.
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.
O'Reilly KB. American Medical News; Nov. 1, 2010.
This article reports on recent study findings indicating that the Universal Protocol has not stopped wrong-patient, wrong-site procedures.
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.
This article describes a wrong-site surgery prevention program and how it was successfully implemented in 30 hospitals.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.
Westfall SS, Mascia K. People. October 5, 2009;72:155.
This story discusses an instance of mistakenly implanted embryos and the impact of the error on the two families involved.