Annals of Emergency Medicine
Volume 55, Issue 6 , Pages 503-509 , June 2010

Patient Identification Errors Are Common in a Simulated Setting

  • Philip L. Henneman, MD

      Affiliations

    • Baystate Medical Center, Springfield, MA
    • Tufts University School of Medicine, Boston, MA
    • Corresponding Author InformationAddress for correspondence: Philip L. Henneman, MD, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199; 413-794-5914, Fax 413-794-8070
    • ,
  • Donald L. Fisher, PhD

      Affiliations

    • College of Engineering, University Massachusetts, Amherst, Amherst, MA
    • ,
  • Elizabeth A. Henneman, PhD, RN

      Affiliations

    • School of Nursing, University of Massachusetts, Amherst, Amherst, MA
    • ,
  • Tuan A. Pham, BA

      Affiliations

    • College of Engineering, University Massachusetts, Amherst, Amherst, MA
    • ,
  • Megan M. Campbell, BSN

      Affiliations

    • School of Nursing, University of Massachusetts, Amherst, Amherst, MA
    • ,
  • Brian H. Nathanson, PhD

      Affiliations

    • OptiStatim, LLC, Longmeadow, MA

Received 6 January 2009 ,Revised 27 October 2009 ,Accepted 18 November 2009.

References 

  1. Joint Commission. National patient safety goals. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoalsAccessed December 12, 2008
  2. Henneman PL, Donald L, Fisher DL, et al. Providers do not verify patient identification during computer order entry. Acad Emerg Med. 2008;15:641–648
  3. Fisher DL, Pradhan AK, Pollatsek A, et al. Empirical evaluation of hazard anticipation behaviors in the field and on a driving simulator using an eye tracker. Transp Res Rec. 2008;2018:80–86
  4. Fordyce J, Blank D, Pekow P, et al. Errors in a busy emergency department. Ann Emerg Med. 2003;42:324–336
  5. Henneman PL, Blank FS, Smithline H, et al. Voluntarily reported emergency department errors. J Patient Saf. 2005;1:126–132
  6. Blank SJ, Henneman PL, Maynard AM, et al. Development and implementation of a patient safety program in an academic, urban emergency department. J Emerg Nurs. 2006;32:491–496
  7. Renner SW, Howanitz PJ, Bachner P. Wrist band identification error reporting in 712 hospitals. Arch Pathol Lab Med. 1993;117:573–577
  8. Hakimzada AF, Green RA, Sayan OR, et al. The nature and occurrence of registration errors in the emergency department. Int J Med Inform. 2008;77:169–175
  9. Bittle MJ, Charache P, Wassilchalk DM. Registration-associated patient misidentification in an academic medical center: causes and corrections. J Qual Patient Saf. 2007;33:25–33
  10. Mulder DR. Care fusion: positive patient identification from Cardinal Health (Pharmacy Purchases & Products May 2007). P 16 http://www.pppmag.com/documents/V5N5/p16.pdfAccessed December 3, 2009
  11. Koppel R, Wetterneck T, Telles JL, et al. Workarounds to barcode medication administration systems: their occurrence, causes, and threats to patient safety. J Am Med Inform Assoc. 2008;15:408–423

 Supervising editor: Robert L. Wears, MD, MS

 Author contributions: PLH, DLH, and EAH conceived the study, designed the trial, and obtained research funding. PLH and DLH supervised the conduct of the trial and data collection. TAP and MMC performed data collection. BHN provided statistical analysis. PLH drafted the article, and all authors contributed substantially to its revision. PLH takes responsibility for the paper as a whole.

 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Supported in part by the National Science Foundation (PLH, DLF, EAH) under awards CCF-0427071, CCF-0829901, 0552548, and 0313747, and the Summer Scholars Program (MMC) for the University Massachusetts Amherst and Baystate Health.

 Reprints not available from authors.

 Provide feedback on this article at the journal's Web site, www.annemergmed.com.

 Please see page 504 for the Editor's Capsule Summary of this article.

 Publication date: Available online December 23, 2009.

PII: S0196-0644(09)01791-0

doi: 10.1016/j.annemergmed.2009.11.017

Annals of Emergency Medicine
Volume 55, Issue 6 , Pages 503-509 , June 2010

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