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Search results for "United States of America"

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Journal Article > Study

Evaluating serial strategies for preventing wrong-patient orders in the NICU.

Adelman JS, Aschner JL, Schechter CB, et al. Pediatrics. 2017;139:e20162863.

Wrong-patient errors are a well-established risk in the health care setting. Research has shown that providers, often multitasking, may enter notes or medication orders for the wrong patient. A prior study touted point-of-care photographs as a helpful intervention for identifying and preventing wrong-patient errors in a cardiothoracic intensive care unit. However, less is known about wrong-patient errors in the neonatal intensive care unit (NICU) population and ways to prevent them. Researchers analyzed more than 850,000 NICU orders and more than 3.5 million non-NICU orders in pediatric patients over a 7-year period. At baseline, they found that wrong-patient orders occurred more frequently in the NICU population with an odds ratio of 1.56. Interventions included requiring reentry of patient identifiers prior to order entry as well as a new naming system for newborns. Implementation of both led to a 61.1% reduction in wrong-patient errors in the NICU population from baseline. A previous WebM&M commentary highlights a case of wrong-patient identification.

Book/Report

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2016 report summarizes information about 336 adverse events that were reported and found that while deaths due to medical error rose, the number of falls and fall-related deaths reached the lowest point since 2011. There were no reported incidence of patient suicide for the first time since 2011. Reports from previous years are also available.

Journal Article > Review

High reliability of care in orthopedic surgery: are we there yet?

Anoushiravani AA, Sayeed Z, El-Othmani MM, Wong PK, Saleh KJ. Orthop Clin North Am. 2016;47:689-695.

High reliability organizations have developed methods for achieving safety despite hazardous conditions. This review explores the importance of establishing a culture of safety and leadership commitment to achieve high reliability in health care. The authors discuss the benefits of applying high reliability principles in orthopedic practice to standardize approaches and prevent wrong-site surgery.

Newspaper/Magazine Article

When doctors get the wrong patient.

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.

Book/Report

Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.

Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.

Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.

Journal Article > Commentary

Disclosure of medical errors involving gametes and embryos.

Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2016;106:59-63.

This publication advocates for open disclosure of errors in reproductive medicine.

Journal Article > Commentary

Effectiveness of surgical safety checklists in improving patient safety.

Ragusa PS, Bitterman A, Auerbach B, Healy WA III. Orthopedics. 2016;39:e307-310.

Checklists are a popular strategy to improve teamwork and prevent errors. Reviewing the evidence on the use of checklists in surgery, this commentary highlights how the tool and associated time out have reduced some adverse events and helped to manage hierarchy in the operating room.

Journal Article > Commentary

Wrong site surgery: a critical incident analysis of a near miss.

Tichanow S. J Perioper Pract. 2016;26:11-15.

Despite efforts to prevent wrong-site surgeries, they continue to occur. This commentary discusses a near miss resulting from human factors and inadequate team communication to underscore the importance of reporting and analyzing incidents to enhance individual practice and teamwork.

Journal Article > Study

Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.

Rebello E, Kee S, Kowalski A, Harun N, Guindani M, Goravanchi F. Health Informatics J. 2016;22:1055-1062.

This electronic audit study examined the incidence of opening and charting in the wrong patient record in the perioperative period. Investigators observed that this error declined over time. They attribute this improvement to time-out procedures and barcoding, both of which facilitate patient identification.

Journal Article > Study

Evaluation of near-miss wrong-patient events in radiology reports.

Sadigh G, Loehfelm T, Applegate KE, Tridandapani S. AJR Am J Roentgenol. 2015;205:337-343.

Despite The Joint Commission requirement to use at least two patient identifiers when obtaining an imaging study, wrong-patient events still occur. This retrospective case review study determined the prevalence of reported near-miss wrong-patient events in radiology at two large academic hospitals. The overall event rate was 4 per 100,000 radiology studies.

Journal Article > Study

Use of temporary names for newborns and associated risks.

  • Classic

Adelman J, Aschner J, Schechter C, et al. Pediatrics. 2015;136:327-333.

Wrong-patient errors are considered to be never events. Newborns are assigned temporary names if they don't have a name immediately after birth, and this may increase the rates of wrong-patient errors. The need for first and last names in electronic health records has led to a generic first name convention of "Babygirl" or "Babyboy," which is in use in more than 80% of neonatal intensive care units in the United States. This pre-post study found that implementing specific first names that incorporated the mother's name reduced the incidence of wrong-patient errors by 36% compared to the generic naming. These errors are rare even at baseline, but given the ease of changing the naming convention, this is a pragmatic approach to improving the safety of computerized provider order entry for hospitalized newborns.

Journal Article > Review

Patient safety in dermatologic surgery part 1. Patient safety in procedural dermatology part 2.

Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. J Am Acad Dermatol. 2015;73:1-26.

This two-part review series explores patient safety in dermatologic practice. The first article discusses safety issues and error reduction tactics in dermatologic surgical practice, highlighting the importance of correct site identification. The second review examines safety problems associated with cosmetic procedures, including complications around nonphysician operators in this field.

Journal Article > Study

Improvement in detection of wrong-patient errors when radiologists include patient photographs in their interpretation of portable chest radiographs.

Tridandapani S, Olsen K, Bhatti P. J Digit Imaging. 2015;28:664-670.

This innovative pilot study found significant improvement in radiologists' ability to detect wrong-patient errors when patient photographs were provided with radiographs. The authors advocate for including photographs with portable radiographs to prevent patient mislabeling errors and augment safety.

Journal Article > Study

Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification.

Nijhawan RI, Lee EH, Nehal KS. Dermatol Surg. 2015;41:499-504.

This study found that encouraging patients to take skin biopsy selfies on smartphones may help patients and physicians more accurately identify the correct biopsy site for subsequent surgical excision, potentially avoiding wrong-site surgeries.

Journal Article > Study

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.

Hudson ME, Chelly JE, Lichter JR. Br J Anaesth. 2015;114:818-824.

Wrong-surgery errors continue to occur despite their status as never events. This study found that wrong-site block occurred at a rate of about 1 per 10,000 nerve blocks, and these persisted even after implementation of time out procedures. The authors highlight the need to develop interventions to prevent these events.

Newspaper/Magazine Article

Wrong-site orthopedic operations on the extremities: the Pennsylvania experience.

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.

Journal Article > Review

Applying fault tree analysis to the prevention of wrong-site surgery.

Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C IV, Mehrotra S. J Surg Res. 2015;193:88-94.

This systematic review investigated root causes of wrong-site surgery and identified three vulnerabilities: transcription errors prior to surgery, intraoperative verification failures, and omitting steps in the verification process. The Universal Protocol does not mitigate these vulnerabilities, suggesting that further interventions are required to prevent wrong-site surgeries. A recent AHRQ WebM&M commentary provides an overview of wrong-site surgery and best practices to prevent it.

Journal Article > Study

Intercepting wrong-patient orders in a computerized provider order entry system.

Green RA, Hripcsak G, Salmasian H, et al. Ann Emerg Med. 2015;65:679-686.

While computerized physician order entry is expected to significantly reduce adverse drug events, systems must be implemented thoughtfully to avoid facilitating certain types of errors. A forcing function that mandated correct patient identification resulted in a moderate decrease in wrong-patient prescribing errors within a computerized provider order entry system.

Audiovisual > Audiovisual Presentation

Patient Safety Essentials for Laboratory Professionals Certificate Program.

Washington, DC: American Association for Clinical Chemistry.

This certificate program for laboratory professionals offers six courses aimed at enhancing participants' skills in establishing a just culture, identifying safety hazards, and assessing gaps in processes to reduce risks of specimen management errors.

Newspaper/Magazine Article

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.

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