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Descriptive analysis of patient misidentification from incident report system data in academic centres

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Euroanaesthesia 2017

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Abstract

Introduction Patient misidentification continues to be an issue in our everyday practice and may be particularly harmful. Incident reporting systems (IRS) are thought to be cornerstones to enhance patient safety by learning from failure and finding common root causes that can be corrected. The aim of this study was to describe common patient misidentification incidents and contributory factors related to perioperative care. Design and Settings We analysed data prospectively reported by healthcare workers in IRS at a large academic hospital’s federation. All patient misidentification incidents that occurred during perioperative care from 2011 to 2014 were reviewed and classified. Incident type, contributory factor, error type, and consequences for the patient and for the organisation were investigated for each incident report. Results Among 293 reported incidents, missing wristbands (34%), wrong charts or note in file (20%), administrative issues (19.4%), and wrong labelling (14%) were the most frequent errors. Main contributory factors included the absence of patient identity control (30.1%), patient transfer (30.1%), and emergency context (8.4%). Data on patient and institutional consequence were scarce. Missing and wrong identity on wristbands events were rarely detected when patients were transferred from the admission ward to the operating room or the radiology department. Conclusion This work contributes to enhance interest in IRS data analysis to focus patient safety improvement strategies related to misidentification errors and weakness, and for their detection inside healthcare institutions.

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© Copyright 2020 Morressier GmbH.
All rights reserved.