Wristbands as aids to reduce misidentification: an ethnographically guided task analysis

Smith, Andrew F; Casey, Kate; Wilson, James J.; Fischbacher‐Smith, Denis

doi:10.1093/intqhc/mzr045

Cited by 24 publications

(35 citation statements)

References 22 publications

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“…Guaranteeing unequivocal patient identification is the main point to prevent mistakes or nonconformities in health care, but it is still challenging and requires well-defined protocols and commitment from professionals (9)(10) . Each healthcare organization has its own identification procedure to keep the process accurate based on standard operating procedures or strategies to improve patient safety (9,(11)(12)(13) . Nevertheless, the identification protocols for wristbands advocate some fundamental measures, such as content clarity, commitment of professionals, registry of the time of placement, removal and substitution of wristbands, description of activities and identification mechanisms in situations in which standard operating procedures cannot be followed, which encompass Evaluation of the risk of misidentification of women in a public maternity hospital Tase TH, Quadrado ERS, Tronchin DMR.…”

Section: Discussionmentioning

confidence: 99%

“…Recognizing the most effective approach to help patients to change behaviors and improve results in health care is considered a significant progress in the quality of services (12,26) . Other situations that expose healthcare professionals to the risk of misidentification include high number of patients, incomplete pronunciation and spelling and sound similarity, among others (2,8,19,21,27) .…”

Section: Discussionmentioning

confidence: 99%

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Evaluation of the risk of misidentification of women in a public maternity hospital

2018

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Objective: To determine the frequency of similar names and hospital records of women in a public teaching maternity hospital and the risk of misidentification resulting from the similarity in spelling and pronunciation of the names and in records. Method: Quantitative, documental and case study of 5,975 admissions that occurred between 2011 and 2014. The data name, admission and discharge date, date of birth, hospital record and bed number were collected from an electronic information system. Analysis encompassed descriptive statistics and design of an algorithm for comparison of text and sound. Results: Examination of the names revealed that 86% of the misidentification cases resulted from identical surnames and 96.5% from a sound similarity in the first names. There were patients with identical first and last names at least one day a week. Conclusion: The risk of misidentification of patients is a reality, which stresses the importance of checking and pronouncing the complete names correctly.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Evaluation of the risk of misidentification of women in a public maternity hospital

2018

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“…As rotinas já estabelecidas asseguram uma zona de conforto aos profissionais, enquanto a proposta de reconfiguração das ações pode desencadear sentimento de insegurança, rejeição e medo. Neste aspecto, a difícil tarefa de implantar novas rotinas foi descrita em estudo anterior, reconhecendo que políticas que visam alterar o comportamento dos praticantes na melhoraria da segurança do paciente têm menos possibilidade de sucesso se não levarem em conta as práticas já existentes (15) .…”

Section: Discussionunclassified

Adesão à identificação do paciente em hospital universitário público

Girardi

Neta²,

Santos³

et al. 2018

Rev. Adm. Saúde

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Estudo transversal cujo objetivo foi identificar a taxa de adesão à identificação do paciente hospitalizado, bem como os principais motivos para sua não aderência. A pesquisa foi realizada em hospital universitário público do Paraná, com uma amostra (n=748) de pacientes internados entre setembro a dezembro de 2016. A coleta de dados foi precedida por observação direta com registro da adesão à pulseira de identificação e motivos para não aderência em um dia aleatório não agendado de cada mês. Aos dados tabulados procedeu-se análise estatística descritiva em medidas de proporção. A taxa geral de adesão à identificação do paciente foi de 71,6%. O melhor resultado de adesão foi constatado no Centro Obstétrico (94,2%); e o pior, na Pediatria, com 61,4% de não adesão. O motivo de não aderência mais frequente se relaciona à perda da pulseira nos setores. Concluiu-se que a adesão à identificação do paciente no hospital ainda é deficitária, e que a melhor comunicação com os setores assistenciais e o serviço de internamento pode ser uma estratégia para a maior adesão.

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“…In a study of how and whether nurses identify patients in a psychiatric hospital setting, it was found that the use of wristbands was erratic and influenced by a psychiatric nursing culture rooted in the belief that (good) nurses know who the patients are 22. The inconsistency in using the patient’s wristband for identification has also been addressed in somatic settings, and it has been shown in simulation tests that as many as 61% of nurses do not discover an unexpected identity error 23,24. This raises a question about how and when nursing culture plays a role in patient safety and whether this brings advantages or barriers.…”

Section: Discussionmentioning

confidence: 99%

The medication process in a psychiatric hospital: are errors a potential threat to patient safety?

Soerensen

Lisby

Nielsen

et al. 2013

RMHP

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PurposeTo investigate the frequency, type, and potential severity of errors in several stages of the medication process in an inpatient psychiatric setting.MethodsA cross-sectional study using three methods for detecting errors: (1) direct observation; (2) unannounced control visits in the wards collecting dispensed drugs; and (3) chart reviews. All errors, except errors in discharge summaries, were assessed for potential consequences by two clinical pharmacologists.SettingThree psychiatric wards with adult patients at Aalborg University Hospital, Denmark, from January 2010–April 2010.The observational unitThe individual handling of medication (prescribing, dispensing, and administering).ResultsIn total, 189 errors were detected in 1,082 opportunities for error (17%) of which 84/998 (8%) were assessed as potentially harmful. The frequency of errors was: prescribing, 10/189 (5%); dispensing, 18/189 (10%); administration, 142/189 (75%); and discharge summaries, 19/189 (10%). The most common errors were omission of pro re nata dosing regime in computerized physician order entry, omission of dose, lack of identity control, and omission of drug.ConclusionErrors throughout the medication process are common in psychiatric wards to an extent which resembles error rates in somatic care. Despite a substantial proportion of errors with potential to harm patients, very few errors were considered potentially fatal. Medical staff needs greater awareness of medication safety and guidelines related to the medication process. Many errors in this study might potentially be prevented by nursing staff when handling medication and observing patients for effect and side effects of medication. The nurses’ role in psychiatric medication safety should be further explored as nurses appear to be in the unique position to intercept errors before they reach the patient.

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Wristbands as aids to reduce misidentification: an ethnographically guided task analysis

Abstract: Wristbands for patient identification are not being used to their full potential. Attention to detail in application and use, especially during handover and transfer, and an appreciation of the role played by 'non-clinical' staff, may offer further gains in patient safety.

Cited by 24 publications

References 22 publications

Evaluation of the risk of misidentification of women in a public maternity hospital

Evaluation of the risk of misidentification of women in a public maternity hospital

Adesão à identificação do paciente em hospital universitário público

The medication process in a psychiatric hospital: are errors a potential threat to patient safety?

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