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- Communication Improvement
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Technologic Approaches 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors
- Medical Complications 1
- Medication Safety 2
- Surgical Complications 2
Search results for "Identification Errors"
Tools/Toolkit > Multi-use Website
Washington State Hospital Association.
This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.