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Intervention efficacy for eliminating patient misidentification using step-by-step problem-solving procedures to improve patient safety.

Abstract：

:This study aimed to evaluate the efficacy of interventions to reduce patient misidentification incidents classified as level 2 and over (adverse events occurred for patients) with the step-by-step problem-solving method. All incidents related to patient misidentification were selected, and relevant information was collected from the original electronic incident reports. We then conducted an eight-step problem-solving process with the aim of reducing patient misclassification and improving patient safety. Step 1: the number of misidentification-related incident reports and the percentage of these reports in the total incident reports increased each year. Step 2: the most frequent misidentification type was sample collection tubes, followed by drug administration and hospital meals. Step 3: we set a target of an 20% decrease in patient misidentification cases classified as level 2 or over compared with the previous year, and established this as a hospital priority. Step 4: we found that discrepancies in patient identification procedures were the most important causes of misidentification. Step 5: we standardized the patient identification process to achieve an 10% reduction in misidentification. Step 6: we disseminated instructional videos to all staff members. Step 7: we confirmed there was an 18% reduction in level 2 and over patient misidentification compared with the previous year. Step 8: we intend to make additional effort to decrease misidentification of patients by a further 10%. Level 2 and over patient misidentification can be reduced by a patient identification policy using a step-by-step problem-solving procedure. This study aimed to evaluate the efficacy of interventions to reduce patient misidentification incidents with step-by-step problem-solving method. Continued seamless efforts to eliminate patient misidentification are mandatory for this activity.

journal_name

Nagoya J Med Sci

journal_title

Nagoya journal of medical science

authors

Fukami T,Uemura M,Terai M,Umemura T,Maeda M,Ichikawa M,Sawai N,Kitano F,Nagao Y

doi

10.18999/nagjms.82.2.315

subject

Has Abstract

pub_date

2020-05-01 00:00:00

pages

315-321

issue

eissn

0027-7622

issn

2186-3326

journal_volume

pub_type

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Intervention efficacy for eliminating patient misidentification using step-by-step problem-solving procedures to improve patient safety.