ISMP

Oops, Sorry, Wrong Patient!

Applying the JCAHO “two-identifier” rule beyond the patient’s room

By the Institue for Safe Medication Practices

When we think of “wrong patient” errors, the most common scenario that comes to mind is a nurse walking into a patient’s room and administering medications intended for one patient to another patient — often a roommate. However, “wrong patient” errors occur in a variety of ways.