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 10
- Legal and Policy Approaches 11
- Logistical Approaches 6
- Quality Improvement Strategies 15
- Teamwork 6
- Technologic Approaches 12
- 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 12
- Nonsurgical Procedural Complications 2
- Surgical Complications 25
- Transfusion Complications 1
- Medicine 40
- Nursing 1
- Pharmacy 2
- Family Members and Caregivers 2
- Health Care Executives and Administrators 26
Health Care Providers
- Nurses 5
- Non-Health Care Professionals 13
- Patients 31
Search results for "Identification Errors"
- Newspaper/Magazine Article
- Identification Errors
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.
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.
ISMP Medication Safety Alert! Acute Care Edition. January 25, 2007;12:1.
This article discusses the weaknesses inherent in using the "five rights" for medication use as absolutes and suggests that they instead serve as broad goals to support safe medication practices.
Edozien L. Saferhealthcare. June 2, 2006.
This article discusses how misidentification can occur in the medical environment and provides several illustrations of its negative consequences.
BBC News. May 16, 2006.
As evidence that identification errors occur in industries other than health care, this article describes how a graduate student interviewing for a job at the BBC studios was mistakenly put on television to comment on a legal case (he haltingly answered three questions and later told the BBC that he would be "happy to return" to "speak about any situation"). This mishap demonstrates the need to use multiple means of identification to avoid "wrong-person" errors.
PA-PSRS Patient Saf Advis. December 2005;2(suppl 2):1-4.
This supplemental advisory recommends that a limited, standard set of colors and corresponding terms accompany wristband use.
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.
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.
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.