When you anticipate of “wrong patient” medication errors in inpatient settings, the best accustomed book that comes to apperception is a assistant walking into a patient’s allowance and administering medications advised for one accommodating to addition patient—often a roommate. Perhaps the accommodating had switched hospital beds with his acquaintance to be afterpiece to the window, or he was sitting on the bend of his roommate’s abandoned bed. Maybe the assistant had absolute the patient’s character during antecedent biologic administering but bootless to analysis it afresh during consecutive administrations that day. Or the action of acceptance the patient’s character was disconnected by a company allurement a question, and the assistant artlessly forgot to complete the analysis process. In any case, one axiological annual of these errors is a awry or absent accommodating identification process.
However, “wrong patient” medication errors can action for a array of affidavit at any point in the accommodating appointment or during any appearance of the medication use process. Examples of hazards, abreast misses, and absolute “wrong patient” errors follow. Fictitious names are provided aback all-important to aback the base of the error.
Omitting Junior/Senior Designation. A patient’s son, John Jones Jr., was registering to accord axis beef for his father, John Jones Sr.1 Afterwards acknowledging the son had ahead been a accommodating in the hospital, the allotment agent amid “John Jones” in the adept accommodating list, printed an armband, and placed the armband on his wrist. The agent was focused on the abstruse aspects of entering data, and little absorption was accustomed to acceptance the patient’s character afore applying the armband. A agent afterwards able that both ancestor and son were cutting identical armbands. Thus, any medications assigned for the ancestor could accept been administered to the son, or carnality versa, alike if the assistant had appropriately articular the patients application name and medical almanac number.
Order Access Error. A dehydrated lung blight accommodating was accustomed to the emergency administering for IV hydration. Addition accommodating from a motor agent blow (MVA) was apprehension intubation and alteration to a bounded agony center. The aforementioned physician was caring for both patients. The physician gave exact orders for vecuronium and midazolam for the MVA patient, but he aback entered the medication orders electronically into the blight patient’s record. The assistant caring for the blight accommodating went on break, and a accoutrement assistant administered the diplegic and allaying to the blight accommodating alike admitting he was not intubated. The accommodating able a respiratory arrest and died.
Reliance on Amiss Accommodating Data. A physician assigned medications for a new accommodating that were based on a medication annual in the history and concrete of the patient’s sister. A pharmacist apparent the absurdity during medication reconciliation.
Mistranscribed Blast Order. A assistant accustomed a blast adjustment for morphine 2 mg IV but transcribed the adjustment assimilate the amiss patient’s record. The adjustment was faxed to the pharmacy and entered as an alive adjustment on the amiss patient’s cyberbanking medication administering almanac (eMAR). The amiss patient, who was already accepting fentaNYL, was accustomed the morphine, which acquired cogent respiratory depression. A accelerated acknowledgment aggregation was called, and naloxone was administered.
Intermingled Accommodating Labels. Aback a consulting physician accustomed on a assemblage to aftereffect with a accepted patient, he abstruse the accommodating and blueprint were both in radiology. The physician wrote several orders on a bare adjustment anatomy and asked the assemblage secretary to add a accommodating label. The labels for all alive patients were kept calm in a distinct book folder. The assemblage secretary amid labels for the actual accommodating but accidentally removed a characterization from addition patient’s food that were appropriate abaft the actual labels. The incorrect characterization was added to the adjustment form. The absurdity was captured afore extensive the amiss patient.
Data Access Errors. To admission an adjustment for a accommodating alleged Franklin Hope, a pharmacist approved to admission the contour application the patient’s identification number. However, the cardinal was ailing arresting on the adjustment anatomy imprint, and the contour could not be located. He afresh entered the patient’s name, Franklin Hope, and a contour appeared on the screen. While entering the order, the pharmacist happened to apprehension that the accommodating was female, not male. He anon able that he had been entering the adjustment into Hope Franklin’s profile, not Franklin Hope’s profile!
Coupled Biologic Delivery. An oncology accommodating accustomed addition patient’s IV chemotherapy admitting accommodating analysis by two nurses afore administration. Typically, the pharmacy dispensed anniversary patient’s chemo-therapy axial a labeled Ziplock bag. In this case, the pharmacy beatific chemotherapy for two patients axial the aforementioned Ziplock bag. Aback the capacity of the bag were removed, the nurses apparent there were chemotherapy accoutrements for two patients. They absolute the aboriginal accommodating and the chemotherapy for that patient, but the assistant administering the chemotherapy accidentally best up the added patient’s chemotherapy bag and administered it to the aboriginal patient.
Reliance on Exact Affirmation of Name. A assistant entered the cat-and-mouse breadth of an oncologist’s appointment and alleged for “Mrs. Jackson” to appear aback to the analysis allowance for her chemotherapy.1 The assistant anxiously arrested the chemotherapy orders adjoin the medical almanac the agent had handed her. Acceptance alone that the accommodating was Mrs. Jackson, the assistant able and administered the chemotherapy. Several hours later, addition accommodating alleged “Mrs. Jackson” accustomed for chemotherapy, and the assistant able she had administered this patient’s chemotherapy to the above-mentioned accommodating alleged “Mrs. Jackson.”
ADC Overrides Entered into eMARs. In two instances, the amiss accommodating was alleged from a accommodating annual on the awning of an automatic dispensing chiffonier (ADC) in a cardiac catheterization (cath) lab. The ADC accustomed admission to all patients in the hospital. This ADC could be configured to absolute admission to patients on up to six units. However, the cath lab bare admission to patients in added than six units, so it was configured to acquiesce admission to all ailing patients. Aback abandoning medications from the ADC in the cath lab, the chase for the actual accommodating was about narrowed by entering the aboriginal allotment of the patient’s annual cardinal or aftermost name, and afresh acrimonious the actual name amid the annual that appeared on the screen. In the two events, nurses afield best the names of breed in the NICU instead of analogously alleged developed patients who were appointed for cardiac catheterizations. Aback the medications were removed from the ADC beneath the infants’ names, it created an override that busy the drugs on the infants’ eMARs. Fortunately, the erroneous entries in the eMARs were noticed afore the breed accustomed the drugs assigned for the developed cardiac cath patients.
Mixing up MARs. The medication administering annal (MARs) for two breed were alloyed up, consistent in the administering of SYNAGIS (palivizumab), acclimated to assure infants/young accouchement from respiratory syncytial virus, to the amiss child. The breed were side-by-side in isolettes, and both MARs were on the adverse amid the two isolettes. Coincidentally, both breed had the aforementioned aboriginal name forth with actual agnate hospital identification numbers. The assistant bootless to apprehension that she was apropos to the amiss MAR and administered a dosage of Synagis to the amiss infant.
Mixing up Ecology Results. A physician assigned CARDIZEM (diltiazem) 20 mg IV followed by 30 mg orally for a accommodating in bed A afterwards a telemetry assemblage assistant alleged to address that his cardiac adviser showed atrial fibrillation and agitate with a affection amount of 140. Aback the accommodating apparent no advance afterwards accepting the drug, the assistant alleged the physician afresh and accustomed an adjustment to administrate 150 mg of amiodarone IV advance followed by a 60 mg per hour infusion. A abbreviate time later, the assistant able that the accent she was examination on the adviser at the nurse’s base was for the accommodating in bed B. The names of the patients in bed A and bed B had been alloyed up and acquaint on the amiss approach of the axial ecology unit.
Safe Practice Recommendations: Aboriginal alien in 2003, The Joint Commission National Accommodating Safety Ambition (NPSG) #1 aims to advance the accurateness of accommodating identification. Today, the ambition requires healthcare practitioners to use at atomic two accommodating identifiers (not the patient’s allowance cardinal or location) aback accouterment care, treatment, and services. The absorbed is two-fold: 1) to anxiously analyze the alone as the being for whom the account or analysis is intended, and 2) to bout the account or analysis to that individual.
The 2011 Elements of Performance for this ambition crave healthcare workers to verify accommodating character application at atomic two identifiers aback administering medications, blood, and claret components; aback accession claret samples and added specimens for analytic testing; and aback accouterment treatments or procedures. Lest you accept that alone tasks associated with biologic administering are included, The Joint Commission has acclaimed in questions and answers on this ambition (http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=145&StandardsFAQChapterId=77 ) that it applies to “other treatments and procedures,” including, for example, prescriber’s orders and advertisement of analysis results.
Thus, accommodating analysis application two identifiers should be able with all patient-associated tasks in the medication use action when:
Physicians appoint medications
Pharmacists and technicians enter/verify orders and allocate medications
Unit secretaries, nurses, and added accustomed agents transcribe medication orders
Nurses and added able healthcare providers administrate medications
Healthcare workers set up, obtain, receive, give, and/or document/file analytic analysis after-effects (which are generally relied aloft for medication prescribing)
Healthcare practitioners participate in added analytical processes.
Nurses should accept the patient’s MAR or eMAR at the bedside for analysis of two different identifiers. Pharmacists and pharmacy technicians who admission orders into the pharmacy computer should baddest the accommodating contour application the patient’s medical almanac cardinal (never the allowance number) or by scanning the barcode on the patient’s characterization on an adjustment set, and afresh affirm the patient’s name and cardinal on the awning by comparing them to the name and cardinal on the orders; assemblage secretaries and nurses should analyze accommodating advice on the adjustment anatomy and MAR aback transcribing orders. However, ensuring that this advice is accessible to physicians in a way that allows allegory of the identifiers for analysis presents a claiming unless computerized prescriber adjustment access (CPOE) systems are in use.
CPOE systems can be advised so that, already logged on, the physician can baddest the name from a annual of patients assigned to him instead of a abundant beyond annual of all patients. In the ambulant setting, a commensurable annual would be the agenda of patients who are to be apparent that day. Enhancing the chantry acclimated for the patient’s name on the awning additionally can advance authentic adjustment access (for pharmacists, too). Some systems can additionally active agents to agnate names in the anthology and crave a additional anatomy of character (e.g., bearing date, identification number) afore proceeding.
Additional strategies to anticipate “wrong patient” medication errors can be begin in Table 1.
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