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- Communication Improvement 8
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 3
- Human Factors Engineering 2
- Legal and Policy Approaches 3
- Quality Improvement Strategies 5
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- Wrong Patient
- Interruptions and distractions 1
- Medical Complications 1
- Medication Safety 5
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Search results for "Wrong Patient"
- Newspaper/Magazine Article
- Wrong Patient
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. ISMP is currently surveying the field to assess the prevalence of the problem. The deadline for submitting data is June 9, 2019.
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.
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.
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.
Bramson K, Mooney T. Providence Journal. August 18, 2006.
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation.
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.
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.
PA-PSRS Patient Saf Advis. June 2007;4:29, 32-45.
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggestions to reduce this type of error.
Szabo L. USA Today. February 5, 2007.
This article suggests ways for patients to play a proactive and informed role in their own safe care. A video entitled "Things you should know before entering a hospital" accompanies the article.
Gray R. Scotland on Sunday. January 8, 2006.
This story discusses the impact of a computer glitch in a system used by more than 80% of general practitioners in Scotland. In addition to physician notes being inadvertently attached to the wrong patient's medical record, reports suggest that some patients actually received incorrect prescriptions due to printing errors caused by the system.