Wrong-Patient Errors Prevalent in Ambulatory Care, Interventions Needed
January 22, 2016 | Strategic Insights for Ambulatory Care
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 inpatient and emergency department settings. An example of the "Swiss cheese" model of error causation, several factors converged in this case to create the error, including the fact that both patients were the same age and had the same first and last names, that the misidentified patient and the receptionist who registered him were new to the practice, and that the practice had recently implemented its electronic health record (EHR) system.