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- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Quality Improvement Strategies
- Technologic Approaches 1
Search results for "Identification Errors"
- Continuous Quality Improvement
- Identification Errors
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.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Journal Article > Study
Registration-associated patient misidentification in an academic medical center: causes and corrections.
Bittle MJ, Charache P, Wassilchalk DM. Jt Comm J Qual Patient Saf. 2007;33:25-33.
In response to multiple incidents of registration-associated patient misidentification (eg, assigning a new patient an existing patient's medical record number), an interdisciplinary team used plan-do-study-act methodology to investigate the root cause of such errors and formulate solutions. Several system problems were identified, ranging from inadequate training of registrars to the lack of a true master list of patients' medical record numbers. The authors describe the iterative process used to identify and address sources of error at several points within the patient registration process.
Cases & Commentaries
- Web M&M
Harold S. Kaplan, MD; February 2004
Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake.