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Title: Toward an error-free reporting system: a case report
Authors: Sajjan Iqbal Memon, Hafsa Syed, Kinza Amin, Arsalan Younas, Gulzar Usman
Journal: Rawal Medical Journal
Publisher: Pakistan Medical Association
Country: Pakistan
Year: 2025
Volume: 50
Issue: 1
Language: English
Keywords: Patient SafetyHealth carequality improvementpatient identificationblood group discrepancyCAPA methodology.
AbstractWrong 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 report emphasizes the necessity for strong patient identification processes, staff training and diagnostic and transfusion errors prevention.Key words: Health care, patient identification, blood group discrepancy, patient safety, quality improvement, CAPA methodology.
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