Toward an error-free reporting system: a case report

Sajjan Iqbal Memon; Hafsa Syed; Kinza Amin; Arsalan Younas; Gulzar Usman

Author(s)

Sajjan Iqbal Memon Quality & Patient Safety Department, Chiniot General Hospital, Karachi, Pakistan

Hafsa Syed NIPRM, Hyderabad Sindh, Pakistan

Kinza Amin The University of Lahore, Punjab, Pakistan

Arsalan Younas Jinnah Post Graduate Medical University, Karachi, Pakistan

Gulzar Usman Department of Community Medicine, Liaquat University of Medical Sciences, Jamshoro, Pakistan

Abstract

Wrong patient identification (WPI) is a critical patient safety issue with potentially life-threatening consequences, such as incorrect blood groupings. This case report examines the use of corrective and preventive action (CAPA) to enhance WPI incident reporting. It emphasizes the importance of structured reporting, risk management, and fostering a culture of learning from errors. A 30-year-old woman was admitted to a tertiary care hospital in Hyderabad, Pakistan. Her blood group was “AB-Positive” in 2019 but changed to “B-Positive” in 2023 owing to many people using the same MR card. Even though there were no immediate solutions, we implemented CNIC verification, patient education, and staff attention to prevent recurrence. This emphasizes the necessity for strong patient identification processes, staff training and diagnostic and transfusion errors prevention.

Publication Details

Page(s) 259-261

DOI DOI not available

Published Journal: Rawal Medical Journal, Volume: 50, Issue: 1, Year: 2025

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Keywords

Health care, Patient safety, Quality improvement, patient identification, blood group discrepancy, CAPA methodology.

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