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Toward an error-free reporting system: a case report


Article Information

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

HEC Recognition History
Category From To
Y 2023-07-01 2024-09-30
Y 2022-07-01 2023-06-30
Y 2021-07-01 2022-06-30
Y 2020-07-01 2021-06-30
Y 2018-03-06 2020-06-30
X 2015-01-23 2018-03-05
Y 2011-05-13 2015-01-22

Publisher: Pakistan Medical Association

Country: Pakistan

Year: 2025

Volume: 50

Issue: 1

Language: English

Keywords: Patient SafetyHealth carequality improvementpatient identificationblood group discrepancyCAPA methodology.

Categories

Abstract

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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