Start Date
5-3-2024 9:10 AM
End Date
5-3-2024 11:00 AM
Description
Background
Context: In this patient safety analysis, the authors review a case in which a patient’s labs collected in a large, quaternary care hospital's ER demonstrated concerning results that significantly deviated from labs drawn only hours prior
Problem Statement: The suspected mislabeling of patient labs resulted in a near-miss for the identified patient and unknown consequences for a second patient
Project AIM: Determine the root causes of this error and identify mechanisms to improve patient safety by reducing the incidence of similar errors
Keywords
patient safety, bookwork, error
Included in
Bad Blood – A Patient Safety Analysis
Background
Context: In this patient safety analysis, the authors review a case in which a patient’s labs collected in a large, quaternary care hospital's ER demonstrated concerning results that significantly deviated from labs drawn only hours prior
Problem Statement: The suspected mislabeling of patient labs resulted in a near-miss for the identified patient and unknown consequences for a second patient
Project AIM: Determine the root causes of this error and identify mechanisms to improve patient safety by reducing the incidence of similar errors
Comments
Patient Safety Honorable Mention Award
Presented at the 2024 Jefferson Health Equity and Quality Improvement (HEQI) Summit.