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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.

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.

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 > 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

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.

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.

Journal Article > Study

A multiobserver study of the effects of including point-of-care patient photographs with portable radiography: a means to detect wrong-patient errors.

Tridandapani S, Ramamurthy S, Provenzale J, Obuchowski NA, Evanoff MG, Bhatti P. Acad Radiol. 2014;21:1038-1047.

Similar to a prior smaller study, this study found the inclusion of point-of-care facial photographs obtained with portable chest radiographs increased the identification of wrong-patient errors among a group of 90 academic radiologists.

Journal Article > Study

Patient identification errors: the detective in the laboratory.

Salinas M, López-Garrigós M, Lillo R, Gutiérreza M, Lugo J, Leiva-Salinas C. Clin Biochem. 2013;46:1767-1769.

Although electronic test ordering resulted in fewer patient identification errors in a clinical laboratory, significant variability in error rates between centers remained, emphasizing the continued effect of human behavior on interventions.

Journal Article > Study

Increasing rate of detection of wrong-patient radiographs: use of photographs obtained at time of radiography.

Tridandapani S, Ramamurthy S, Galgano SJ, Provenzale JM. AJR Am J Roentgenol. 2013;200:W345-W352.

Automatically photographing patients at the time of portable chest radiography increased the detection of mislabeled radiograph errors without significantly affecting film interpretation time.

Journal Article > Study

Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

Galanter W, Falck S, Burns M, Laragh M, Lambert BL. J Am Med Inform Assoc. 2013;20:477-481.

Wrong-patient errors have long been a risk in hospitals. In one seminal case, a patient underwent an invasive procedure intended for another patient with a similar name. In the era of electronic medical records, errors such as entering notes or ordering medications for the wrong patient may occur as a consequence of multitasking. This AHRQ-funded study evaluated the effectiveness of an alert system, which required entry of an appropriate clinical diagnosis, at preventing wrong-patient medication errors in a computerized provider order entry system. Although the system did correctly identify and prevent incorrect prescriptions, 4000 alerts were required to prevent a single error. Other studies have successfully used forcing functions, or simply placing the patient's photograph on the order screen, to prevent wrong-patient errors.

Journal Article > Study

Matching identifiers in electronic health records: implications for duplicate records and patient safety.

McCoy AB, Wright A, Kahn MG, Shapiro JS, Bernstam EV, Sittig DF. BMJ Qual Saf. 2013;22:219-224.

The presence of duplicate records (a single patient having multiple medical records within the same system) is a risk factor for preventable errors. This study at five academic medical centers found that duplicate records were common, with the incidence varying widely across centers.

Journal Article > Study

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.

Adelman JS, Kalkut GE, Schechter CB, et al. J Am Med Inform Assoc. 2013;20:305-310.

Patient misidentification errors—such as laboratory results or notes being entered into the wrong patient chart—have been shown to occur in the emergency department and inpatient settings. Misidentification errors have the potential for serious patient harm when combined with computerized provider order entry, as patients could receive unintended medications. In this study, investigators at an academic medical center first developed a measurement tool within their electronic medical record to identify wrong-patient orders (and found that they were surprisingly common), then conducted a randomized trial investigating the efficacy of two different strategies to prevent wrong-patient orders. A forcing function that mandated re-entry of patient identifiers before allowing order entry resulted in significant reduction in wrong-patient orders. In another study, simply placing the patient's photograph on the order entry screen also appeared to reduce wrong-patient orders.

Journal Article > Study

The use of patient pictures and verification screens to reduce computerized provider order entry errors.

Hyman D, Laire M, Redmond D, Kaplan DW. Pediatrics. 2012;130:e211-e219.

This study implemented an order verification screen, including the patient's photograph, to reduce the risk that orders will be placed in an unintended patient's electronic health record. In a limited analysis, it appeared to be effective.

Journal Article > Study

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.

Journal Article > Study

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.

Journal Article > Study

Minimizing electronic health record patient–note mismatches.

Wilcox AB, Chen YH, Hripcsak G. J Am Med Inform Assoc. 2011;18:511-514.

This study noted a 0.3% patient–note mismatch rate (i.e., finding a note in another patient's record), and the authors suggest that the rate depends highly on the user interface design of the system.

Newspaper/Magazine Article

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.

Journal Article > Study

Variation in surgical time-out and site marking within pediatric otolaryngology.

Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.

Journal Article > Commentary

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

This article describes how an anatomic marking form was developed, discusses its use, and reveals the effect of this process on patient safety.

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