Patient Identification Errors Are Common in a Simulated Setting

Henneman, Philip L.; Fisher, Donald L.; Henneman, Elizabeth A.; Pham, Tuan Anh; Campbell, Megan M.; Nathanson, Brian H.

doi:10.1016/j.annemergmed.2009.11.017

Cited by 59 publications

(59 citation statements)

References 8 publications

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“…All nurses wore an eye-tracking device that included a camera for recording a video with crosshairs showing where each nurse was looking throughout the process. In both experiments, nurses were told that the purpose of the study was to evaluate how healthcare workers use visual cues to perform tasks (Henneman et al, 2010); thus, they were not aware that the purpose of the study was to evaluate the VPI process.…”

Section: Study Proceduresmentioning

confidence: 99%

“…Further studies have shown that approximately 26%-38% of medication errors occur during medication administration (Andersson and Townsend, 2010;Leape et al, 1995) and that up to 80% of these medication administration errors may be due to patient misidentification (Lisby et al, 2005). Although patient identification may appear straightforward, studies have shown it to be complex and errorprone (Henneman et al, 2010;Mannos, 2003;National Patient Safety Agency, 2004;Sevdalis et al, 2009;Spruill et al, 2009).…”

Section: Introductionmentioning

confidence: 95%

“…Moreover, patient misidentification may also harm the patients who fail to receive their intended medications because their medications were erroneously given to other patients (Hakimzada et al, 2008;Ranger and Bothwell, 2004). Most medication error studies to date have focused on reporting patient misidentification statistics from case studies (Henneman et al, 2010;Henneman et al, 2012;Leape et al, 1995), on classifying types of patient identification errors (Mannos, 2003;National Patient Safety Agency, 2004;Schulmeister, * Corresponding author: 2008), or on evaluating the impact of technology on the patient identification process (Henneman et al, 2012;Patterson et al, 2002;Snyder et al, 2010).…”

Section: Introductionmentioning

confidence: 97%

“…3. We evaluate whether nurses comply with these requirements when administering medications by analyzing data from clinical simulations (Henneman et al, 2010;Henneman et al, 2012). For those nurses who do not comply with these requirements, we analyze what they did incorrectly.…”

Section: Introductionmentioning

confidence: 99%

“…These studies, however, appear to focus on specific processes (e.g., medication administration, chemotherapy), specific artifacts (e.g., patient's ID band, patient's chart, chemotherapy product label, medication order), or specific identifiers (e.g., patient's name, MRN). Henneman et al (2010) suggest a strategy that is applicable to any number of artifacts for a set of selected processes. First, their strategy proposes using any two patient identifiers suggested by the Joint Commission and matching those identifiers between two specific artifacts: the patient's ID band and the patient's statements about their identity.…”

Section: Introductionmentioning

confidence: 99%

See 4 more Smart Citations

Re-examining the requirements for verification of patient identifiers during medication administration: No wonder it is error-prone

Jo¹,

Marquard

Clarke³

et al. 2013

IIE Transactions on Healthcare Systems Engineering

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Patient identification errors are one of the major causes of medication errors. Most medication error studies to date have focused on reporting patient misidentification statistics from case studies, on classifying types of patient identification errors, or on evaluating the impact of technology on the patient identification process, but few have proposed specific strategies or guidelines to decrease patient identification errors. Our study makes three key contributions to the patient identification literature. To better understand the verification of patient identifiers (VPI) process, we first formalize the requirements for this process based on the Joint Commission's national patient safety guidelines. Second, we show the implications of these requirements by applying them to artifacts typically used in medication administration (e.g., patient's statements about their identity, patient's identification band, medication label, and medication order). Third, we evaluate whether nurses comply with these requirements when administering medications using data from clinical simulations. We found that nurses must choose from a considerable number of alternatives to fulfill the Joint Commission guidelines. Despite the number of available alternatives, a small percentage of nurses complied with the requirements for VPI, whether doing so manually or using barcode verification technology. Our findings suggest further study is needed to determine what strategies might improve compliance.

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Section: Study Proceduresmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 95%

Section: Introductionmentioning

confidence: 97%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Re-examining the requirements for verification of patient identifiers during medication administration: No wonder it is error-prone

Jo¹,

Marquard

Clarke³

et al. 2013

IIE Transactions on Healthcare Systems Engineering

Self Cite

View full text Add to dashboard Cite

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Application of Electronic Health Records to the Joint Commission's 2011 National Patient Safety Goals

Radecki

Sittig

2011

JAMA

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INCE PUBLICATION OF TO ERR IS HUMAN, ELECTRONIC health records (EHRs) and related health information technologies have been promoted as means to improve patient safety. This promise remains largely unfulfilled. For instance, whereas EHRs with clinical decision support (CDS) interventions integrated into computerized physician order entry (CPOE) have measurably improved clinicians' performance on process metrics, 1 their effect on patient outcomes remains unconfirmed. 2 Recently, the US Department of Health and Human Services (DHHS) launched "Partnership for Patients: Better Care, Lower Costs" by committing $1 billion to improve safety. 3 Meanwhile, EHR vendors and health care organizations have focused considerable effort on meeting standards for "meaningful use" of EHRs as required by the DHHS for incentive payments.Each year, the Joint Commission issues a concise National Patient Safety Goal (NPSG) advisory identifying the highest-priority topics for quality care. 4 Ideally, addressing the NPSGs should be incorporated into the EHR certification process, requiring each vendor to specifically engineer targeted solutions and each organization to carefully implement and use these systems to improve safety. For 2011, the NPSG priorities for hospital quality improvement initiatives are patient identification, staff communication, medication labeling, infection control practices, medication reconciliation and interactions, and mitigation of suicide risks.Electronic health records, along with CPOE, CDS, and bar code medication administration (BCMA), if designed, developed, implemented, and used correctly, potentially play critical roles in addressing these safety goals. In this Commentary, we provide an overview of these goals, current EHR solutions and shortcomings, and potential for improvement. Safe Use of MedicationsElectronic health records with CDS and BCMA integrated into the medication order-verification-administration work-See also p 90.

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A red‐flag‐based approach to risk management of EHR‐related safety concerns

Sittig¹,

Singh

2013

J of Healthc Risk Manag

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Although electronic health records (EHRs) have a significant potential to improve patient safety, EHR-related safety concerns have begun to emerge. Based on 369 responses to a survey sent to the memberships of the American Society for Healthcare Risk Management and the American Health Lawyers Association and supplemented by our previous work in EHR-related patient safety, we identified the following common EHR-related safety concerns: (1) incorrect patient identification; (2) extended EHR unavailability (either planned or unplanned); (3) failure to heed a computer-generated warning or alert; (4) system-to-system interface errors; (5) failure to identify, find, or use the most recent patient data; (6) misunderstandings about time; (7) incorrect item selected from a list of items; and (8) open or incomplete orders. In this article, we present a "red-flag"-based approach that can be used by risk managers to identify potential EHR safety concerns in their institutions. An organization that routinely conducts EHR-related surveillance activities, such as the ones proposed here, can significantly reduce risks associated with EHR implementation and use.

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Patient Identification Errors Are Common in a Simulated Setting

Cited by 59 publications

References 8 publications

Re-examining the requirements for verification of patient identifiers during medication administration: No wonder it is error-prone

Re-examining the requirements for verification of patient identifiers during medication administration: No wonder it is error-prone

Application of Electronic Health Records to the Joint Commission's 2011 National Patient Safety Goals

A red‐flag‐based approach to risk management of EHR‐related safety concerns

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