title: [Switch of patients undergoing an endoscopic procedure].
abstract: Due to a switch in patients, the wrong patient, an 85-year-old man, underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy. The mistake was reported to the healthcare inspectorate. A systematic analysis of the incident using the "Prevention and recovery information system for monitoring and analysis" (PRISMA) method brought to light various shortcomings in the care process. Based on the PRISMA analysis various measures were taken, including the introduction of a time-out procedure with a checklist before carrying out an ERCP. These measures improved the quality of the care process.
authors.affiliation: Medisch Centrum Alkmaar, afd. Maag- Darm- en Leverziekten, Alkmaar, the Netherlands. m.klemt-kropp@planet.nl
authors.forename: Michael
authors.initials: M
authors.lastname: Klemt-Kropp
authors.forename: Sylvia M G A
authors.initials: SM
authors.lastname: van der Lans
mesh_terms: D000369:Aged, 80 and over; D002760:Cholangiopancreatography, Endoscopic Retrograde; D003695:Delivery of Health Care / Q000592:standards*; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000009:adverse effects / Q000191:economics; D009426:Netherlands; D010355:Patient Identification Systems; D011787:Quality of Health Care; D016717:Sphincterotomy, Endoscopic