Wrong-Patient Errors Prevalent in Ambulatory Care, Interventions Needed

January 27, 2016 | Strategic Insights for Health System


​Multiple strategies are needed to prevent wrong-patient errors, states a case and commentary about a patient identification error occurring in an ambulatory setting featured in the Agency for Healthcare Research and Quality's January 2016 WebM&M. The case examines a wrong-patient error that resulted in a 55-year-old man receiving test results and instructions from a provider that were intended for another patient. The article notes that wrong-patient orders occur at a higher rate in ambulatory care than in emergency department and inpatient settings. An example of the "Swiss cheese" model of error causation, several factors converged in this case to create the error; the two patients were the same age and had the same first and last names; both the misidentified patient and the receptionist who registered him were new to the practice; and the practice had recently implemented its electronic health record (EHR) system.

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