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- Error Reporting and Analysis
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Search results for "Error Reporting"
- Error Reporting
- Wrong Patient
Journal Article > Study
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
Adelman JS, Applebaum JR, Southern WN, et al. JAMA Pediatr. 2019 Aug 26; [Epub ahead of print].
A classic study found that the replacing the usual naming convention for newborns ("Babygirl" or "Babyboy") with one incorporating the mother's first name (e.g., "Marysgirl" or "Marysboy") reduced wrong-patient errors. Based on this finding, The Joint Commission issued a National Patient Safety Goal (NPSG) requiring the use of distinct naming systems for newborns. The authors of this study noted that the new standard would still leave multiple-birth infants vulnerable to wrong-patient errors, as most hospitals adopted naming standards that left room for confusion between infants (e.g., twin infants might be named "Marysgirl1" and "Marysgirl2"). Researchers examined the rate of wrong-patient errors in six neonatal intensive care units of two health systems that used the NPSG recommended naming conventions, comparing multiple-birth infants to singleton infants. They measured wrong-patient errors by tracking the rate of orders that were retracted and then immediately reordered for a different patient. The rate of wrong-patient errors was significantly higher among multiple-birth infants, most of which could be explained by intrafamilial errors (e.g., a medication was ordered for one twin when intended for another). The accompanying editorial points out that this study is an important example of carefully assessing the real-world impact of novel policies; in this case, the NPSG likely does protect against wrong-patient errors for singleton infants, but not for multiple-birth infants.
Journal Article > Study
Effect of restriction of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial.
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Journal Article > Commentary
The wicked problem of patient misidentification: how could the technological revolution help address patient safety?
Ferguson C, Hickman L, Macbean C, Jackson D. J Clin Nurs. 2019;28:2365-2368.
Patient misidentification can result in incorrect diagnosis, treatment, and medication administration. This commentary discusses the practice of auditing patient identification wristbands to assess compliance and accuracy. The authors suggest that technological interventions such as smartphone facial recognition and barcode technologies be considered as strategies to avoid patient misidentification.
Journal Article > Review
Cohen R, Ning S, Yan MTS, Callum J. Transfus Med Rev. 2019:33:78-83.
Inaccurate patient registration can result in information gaps that contribute to delay, misunderstandings, and harm. This review discusses registration errors in the blood transfusion process. The authors discuss how problems can occur during various stages in the transfusion process and result in blood-type discrepancies. They suggest improved reporting of identification mistakes and use of photo identification tools as strategies to prevent patient harm associated with registration errors.
Journal Article > Study
Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.
Hensley NB, Koch CG, Pronovost PJ, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.