Patient Identification Errors Research Articles

Identifying and Addressing Errors in Anatomical Pathology: A Survey Analysis

Abstract Introduction/Objective To get an update on potential sources of pre-analytical, analytical, post-analytical and other sources of errors in anatomic pathology and strategies to mitigate such errors. Methods/Case Report The authors designed a 5-question survey in Google software and shared it widely on social media platforms. Results (if a Case Study enter NA) The survey, which garnered 43 responses from staff across various areas of the anatomic pathology laboratory, revealed significant insights. Labeling and fixation/preservation errors emerged as the most prevalent pre-analytical errors, while discrepancies between gross and microscopic examinations were common analytical errors. Specimen handling, inadequate clinical information, and transportation were the most frequently perceived other potential sources of errors. The implications of these findings are clear: robust protocols with multiple identifiers, staff training, and barcode labeling can significantly reduce patient identification errors. Similarly, standardized collection instructions, pre-labeled containers, and meticulous verification processes can effectively minimize such errors. Validated tests, standardized scoring systems, and proper investigation of quality control discrepancies are key to reducing analytical errors. Documented procedures, staff training, regular equipment calibration, and reagent testing are also crucial. Conclusion This study contributes to the literature on the current state of potential sources of errors in anatomic pathology. The study findings and recommendations on strategies to address such errors would improve the performance of the anatomic pathology laboratory and eventually improve patient care.

Lean approach applied to the blood gas system in point-of-care testing (POCT): The IRCCS San Gerardo dei Tintori experience

ABSTRACT Costs of medical care have increased worldwide, which may be due to unnecessary operational inefficiency. Different approaches exist to enhance procedural processes, and the Lean concept is used to improve quality and performance by systematically eliminating waste. In this study, Lean methodology with the four-stage Deming cycle (Plan, Do, Check, and Act) was applied to the point-of-care testing (POCT) system of the IRCCS San Gerardo dei Tintori. Starting from the evaluation of the current strategies used in the clinical laboratory, our goal was to facilitate workflow standardization, increase the efficiency, appropriateness, and quality standards in the execution of blood gas analysis in POCT, and to plan improvements, staff satisfaction, and safety. Six qualitative key process indicators, such as workflow, work area management, visual checks, reagents and supplies inventory, sample traceability, and work standardization, were used to investigate problems and identify solutions. The adoption of cutting-edge technologies, the training of personnel on the best pre-analytical practices, the standardization of cleaning procedures, the distribution of easy check workflow charts, and standardized material request documents reduced manual operations from 70 to 40% and patient identification errors of 10x. This approach created a diffuse collaborative culture and improved standardization of processes and safety.

Investigating the Professional Commitment and its Correlation with Patient Safety Culture and Patient Identification Errors: Evidence from a Cross-Sectional Study from Nurses' Perspectives

Introduction Nurses' professional commitment is crucial to their qualifications, impacting patient safety. This study aims to explore the relationship between nurses' professional commitment and patient safety culture, specifically focusing on patient identification errors. Methods A cross-sectional study was conducted in 2022 involving 340 nurses working in educational medical hospitals in southern Iran. Data collection instruments included questionnaires on nurses' professional commitment, patient identification errors, and patient safety culture. Descriptive and inferential statistics, such as t-tests, ANOVA, Pearson's correlation coefficient, and multiple linear regression, were performed using SPSS software version 23, with a significance level set at p = 0.05. Results The mean scores for professional commitment, patient safety culture, and errors in patient identification, as perceived by the nurses, were 77.64 ± 14.32 (out of 130), 2.71 ± 0.78 (out of 5), and 16.41 ± 4.58 (out of 32), respectively. There was a statistically significant correlation between professional commitment and errors in patient identification (r = -0.577, p < 0.001) as well as patient safety culture (r = 0.456, p < 0.001). Regression analysis revealed that nursing job satisfaction, understanding of nursing, self-sacrifice for the nursing profession, and engagement with the nursing profession were predictors of patient safety culture and errors in patient identification (p < 0.05). Conclusion Nurses' professional commitment was found to be at a moderate level. Furthermore, the dimensions of professional commitment significantly influenced patient safety culture and errors in patient identification. To enhance nurses' professional commitment, and subsequently improve patient safety culture and reduce identification errors, it is recommended to implement management mechanisms that increase job satisfaction, understanding, engagement, and professional self-sacrifice among nurses.

Biometrics in healthcare as a technological contribution to mitigate patient identification errors: A Review

Biometrics in healthcare as a technological contribution to mitigate patient identification errors: A Review

Patient Re-Identification Based on Deep Metric Learning in Trunk Computed Tomography Images Acquired from Devices from Different Vendors

During radiologic interpretation, radiologists read patient identifiers from the metadata of medical images to recognize the patient being examined. However, it is challenging for radiologists to identify “incorrect” metadata and patient identification errors. We propose a method that uses a patient re-identification technique to link correct metadata to an image set of computed tomography images of a trunk with lost or wrongly assigned metadata. This method is based on a feature vector matching technique that uses a deep feature extractor to adapt to the cross-vendor domain contained in the scout computed tomography image dataset. To identify “incorrect” metadata, we calculated the highest similarity score between a follow-up image and a stored baseline image linked to the correct metadata. The re-identification performance tests whether the image with the highest similarity score belongs to the same patient, i.e., whether the metadata attached to the image are correct. The similarity scores between the follow-up and baseline images for the same “correct” patients were generally greater than those for “incorrect” patients. The proposed feature extractor was sufficiently robust to extract individual distinguishable features without additional training, even for unknown scout computed tomography images. Furthermore, the proposed augmentation technique further improved the re-identification performance of the subset for different vendors by incorporating changes in width magnification due to changes in patient table height during each examination. We believe that metadata checking using the proposed method would help detect the metadata with an “incorrect” patient identifier assigned due to unavoidable errors such as human error.

Relationship between nurses knowledge level and workload about implementation of patient identification

Patient safety incidents can originate from patient identification errors. From the preliminary study, it was found that there were 3 cases of patient identification errors in the year 2022. The objective of this research was to determine the relationship between nurses knowledge level and workload with patient identification implementation. This study employed a quantitative method with a cross-sectional research design. This research aims to analyze the relationship between variables where the independent variable and dependent variable are identified at one unit of time. In this case, to determine the relationship between the level of knowledge and workload of nurses with the implementation of patient identification. The sample consisted of 93 individuals distributed across the inpatient wards. The research sample was selected used random sampling. The knowledge level and workload of nurses were independent variables, while the implementation of patient identification was the dependent variable. Data collected was used of a level of knowledge, workload, and application of identification questionnaire. Data analyzed used were with Chi-square test. The obtained p-value for the relationship between nurses knowledge level and the implementation of patient identification is p=0.018 (p<0.05). Therefore, there is a significant relationship between nurses knowledge level and the implementation of patient identification. P-value for the relationship between nurses workload and the implementation of patient identification is p=0.564 (p>0.05). This explains that there is no significant relationship between nurses workload and the implementation of patient identification. There is a significant relationship between nurses knowledge level and the implementation of patient identification. The majority of nurses demonstrated a good implementation of patient identification. It is recommended for the hospital management to make efforts to improve nurses knowledge, especially in the area of patient safety.

Penerapan Sasaran Keselamatan Pasien di Rumah Sakit: Literatur Review

This study examines how the literature review regarding the implementation of patient health goals in hospitals. The research used in this research is a qualitative research which is described descriptively. Various sources were processed in this study such as books, research results, journals, and research articles. The results of this study are patient safety is a variable for measuring and evaluating the quality of hospital services that have an impact on health services. One of the safety services in this hospital is the application of patient safety goals which starts with the accuracy of patient identification. This is because patient identification errors at the beginning of the service will continue to the next service error. Patient Safety Goals encourage specific improvements in patient safety including the Hospital Patient Safety Goal Standards. All of this must be done considering the complexity of hospital operations, of course, has the potential for errors. Furthermore, patient safety will have an impact on the patient's medical condition and increase health costs.

The Experience of Patient Safety Error for Nursing Students in COVID-19: Focusing on King's Conceptual System Theory.

Some nursing students experience errors related to patient safety, such as falls, medication administration errors, and patient identification errors during clinical practice. However, only a few nursing students report errors during clinical practice. Accordingly, the present study aimed to investigate patient safety errors that nursing students experience during clinical practice in the context of the COVID-19 pandemic. This study conducted in-depth interviews with 14 candidates for graduation from the Department of Nursing at a university in South Korea. In addition, after transcribing the collected data, a directed content analysis for the data based on King's interacting system theory was performed. As a result, four core categories were identified: (i) nursing students' perception of patient safety error occurrence, (ii) interaction between nursing students and others, (iii) interaction between nursing students and organizations, and (iv) nursing students' training needs related to patient safety errors. Consequently, this study identified the patient safety error-related experiences of nursing students during clinical practice during the COVID-19 pandemic. The results suggest that in the future, nursing education institutions must establish a system for nursing students to report patient safety errors during clinical practice for patient safety education and develop practical and targeted education strategies in cooperation with practice training hospitals.

Patient Identification Errors in the Hospital Setting: A Prospective Observational Study

Background and aim: In every aspect of clinical care, including diagnostic testing and medication administration, patient identification (ID) errors can disrupt care and harm patients. The study assesses healthcare workers' frequency and accuracy in verifying patient identity before performing common tasks and develops a proposed patient verifying identity program clinical model to meet the training needs of healthcare workers. Methods: An observational cross-sectional study was conducted at Al-Najaf Teaching Hospital from March to May 2022. Data collection was done through a questionnaire and participatory observation. Hundred-forty healthcare workers participated in the study: 52 clinic doctors, 27 registered nurses, 34 information officers, 17 pharmacists, 4 radiologists, and 6 outpatient hospital doctors. Results: The majority of participants (62.1%) were female. The majority of the 40 participants (28.6%) worked in the operating room. Furthermore, the majority of the participants (82.1%) did not ask the patients for their names and dates of birth (DOB). Clinic doctors made up the majority of those who did not complete the identification process (37.1%). Conclusion: More than three-quarters of healthcare workers missed patient identification while performing a task. Although patient identification errors frequently result in serious adverse events that can be avoided with better training, better use of technology may improve the way healthcare workers verify patients' identities.

Patient safety in hemodialysis clinics: perception of the nursing team.

To analyze the perception of the nursing team regarding patient safety in hemodialysis clinics. Descriptive-exploratory study with a qualitative approach, conducted with 37 professionals from the nursing team of five hemodialysis clinics, located in the cities of Sobral and Fortaleza, in Ceará, Brazil. Data were collected from October to December 2021, through semi-structured interviews recorded and analyzed by Descending Hierarchical Classification. Four classes emerged: operation of hemodialysis clinics; role of companions and patients in their safety in hemodialysis clinics; role of the nursing team in the safe care of patients undergoing hemodialysis; international patient safety goals in hemodialysis clinics. The participants recognize the existence of shortcomings in international patient safety goals, mainly errors in patient identification and medication administration.

Identificación del paciente en la prevención de errores y eventos adversos: revisión sistemática

Introduction: When it comes to patient safety, physicians make efforts to avoid any harm that may be caused to the patient during treatment or therapy, which is an important aspect of healthcare. Patient identification plays a crucial role in the healthcare system and involves several steps to ensure patient safety. This helps to address deficiencies and prevent medical errors and/or adverse events. Objectives: To describe the scientific evidence regarding correct patient identification as a factor in reducing adverse events and medical errors. Methods: A systematic literature review was conducted in Scopus, Web of Science, and Pubmed. Conclusions: Labeling and/or double verification systems for patients or samples in hospital settings resulted in a significant decrease in patient identification errors. However, due to the small sample size of the studies found, standardization is necessary for future meta-analyses or recommendations with a higher level of evidence. The importance of accurate patient identification in the healthcare setting was highlighted, and strategies to improve patient identification accuracy and reduce patient identification errors were presented.

Towards Safe Patient Identification Practices: the Development of a Conceptual Framework from the Findings of a Ph.D. Project

Patient identification errors are considered the root cause of other patient safety incidents. Despite the development, recommendation, and application of several initiatives to reduce and prevent misidentification in hospital settings, errors continue to occur. They directly impact the quality of care provided, resulting in delays in care, added costs, unnecessary injuries, misdiagnosis or wrong treatment, and other serious and irreversible types of harm and death. Furthermore, the certainty of the evidence of the effectiveness of interventions to reduce patient identification errors is considered very low. This paper reports on the development of a conceptual framework for safe practices in the area of patient identification. The proposed conceptual framework was developed based on presuppositions regarding learning health systems and the available evidence from the published systematic reviews of the effectiveness of interventions in reducing patient identification errors in hospital settings. The core circle of the framework represents the partnership between managers, healthcare professionals, patients, and families working toward integrative and collaborative efforts for safe patient identification practices. The inner dimension states the recommendations for practice sustained by applying technological resources and educational strategies to raise awareness of the importance of accurate patient identification and interdisciplinarity, which works as an axis that supports integrated and collective work between healthcare professionals aiming for safe care. The outer dimension represents recommendations for teaching and research to develop effective patient identification practices that can enhance patient safety and the quality of care provided in hospital settings. This framework provides a valuable method for engaging interdisciplinary teams to improve the safety of patient identification systems.

Evaluating Patient Identification Practices During Intrahospital Transfers: A Human Factors Approach.

Reliable patient identification is essential for safe care, and failures may cause patient harm. Identification can be interfered with by system factors, including working conditions, technology, organizational barriers, and inadequate communications protocols. The study aims to explore systems factors contributing to patient identification errors during intrahospital transfers. We conducted a qualitative study through direct observation and interviews with porters during intrahospital patient transfers. Data were analyzed using the Systems Engineering Initiative for Patient Safety human factors model. The patient transfer process was mapped and compared with the institutional Positive Patient Identification policy. Potential system failures were identified using a Failure Modes and Effects Analysis. A total of 60 patient transfer handovers were observed. In none of the evaluable cases observed, patient identification was conducted correctly according to the hospital policy at every step of the process. The principal system factor responsible was organizational failure, followed by technology and team culture issues. The Failure Modes and Effects Analysis methodology revealed that miscommunication between staff and lack of key patient information put patient safety at risk. Patient identification during intrahospital patient transfer is a high-risk event because several factors and many people interact. In this study, the disconnect between the policy and the reality of the workplace left staff and patients vulnerable to the consequences of misidentification. Where a policy is known to be substantially different from work as done, urgent revision is required to eliminate the serious risks associated with the unguided evolution of working practice.

The Effect Of Implementation Of Patient Identification Based On The Pall Accreditation Standards On Improving The Patient Safety Program At Royal Prima General Hospital In 2022

Patient safety is a variable to measure and evaluate the quality of nursingservices that have an impact on health services. One of the safety services inhospitals starts from the accuracy of patient identification. Patientidentification errors at the beginning of the service will continue to the nextservice error. The purpose of this study was to determine how the effect ofimplementing patient identification based on JCI accreditation standards onimproving the Patient Safety program at Royal Prima Hospital. This type ofresearch is a quantitative study with a cross-sectional design. Samplingtechnique The sampling technique in this study was to use the Slovinformula with a total sample of 124 patients. Data analysis in this study usedunivariate and bivariate analysis. The results of the study explained thatthere was an influence between the implementation of patient identificationbased on the Plenary accreditation standard to the improvement of thePatient Safety program at the Royal Prima Hospital Medan with ap value of<0.007. Through this research, it is hoped that the Royal Prima HospitalMedan can improve the quality of nursing services, especially in theimplementation of identification based on the Plenary AccreditationStandards.

Using a Patient Identification Checklist: How to Make This a Never Safety Event in Perioperative Services

<h3>Background Information</h3> Patient identification is one of the Joint Commission National Patient Safety Goals. Positive patient identification involves accuracy, verification and two-way communication. Occasionally, patient armbands did not match patient labels or paperwork, leading to incorrect patient identification. Safety Events were placed and reviewed at the executive level as high-risk safety events that achieved institutional support. Preoperatively, errors in patient identification can lead to potentially serious errors. The check-in area was able to identify workflow inconsistencies, interview techniques and equipment locations as opportunities for improvement. The focus was on patient wristbands during check in, leading to the development of a checklist and subsequent audits to measure compliance. <h3>Objectives of Project</h3> To maintain a trend of overall reported patient ID events, to sustain no high harm and reduce patient ID reported procedures events, as they relate to safety culture and accountability by 25% six months after training in Just Culture and accountability. <h3>Process of Implementation</h3> A review of current workflow and observation audits were completed prior to beginning the pilot. A Patient Identification Checklist supporting hospital policy was developed. Education to staff and 50 in-person audits were completed to observe the wristband check-in process, using an electronic audit. The checklist was laminated and posted at eye level of the Patient Service Coordinator (PSC). The wristband and label printer were relocated closer to the workstation for ease of use. The patient charts filing order was changed from OR room number to alphabetical order (by last name) to reduce chart adjustments. The level of lighting was also adjusted to improve visualization by patients and staff. <h3>Statement of Successful Practice</h3> The baseline data included five patient ID safety events for PACU/Preop and the implementation of the new workflow resulted in zero patient ID events after the pilot. The patient ID wristband checklist helped reduce the number of patient ID events related to wristbands but is dependent on the employee adhering to the checklist. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Not verifying patient information is a top causal factor for patient ID overall. Reminding staff about the importance of adhering to the checklist and following best practice standards for patient identification can help ensure this becomes a Never Event in Perioperative Services.

Survey-based Evaluation of the Use of Picture Archiving and Communication Systems in an Eye Hospital-Ophthalmologists' Perspective.

Picture archiving and communication system (PACS) is a medical imaging system for sharing, storage, retrieval, and access of medical images stored. Our study aimed to identify ophthalmologists' views on PACS, with the comparison between 3 platforms, namely electronic patient record (ePR), HEYEX (Heidelberg Engineering, Switzerland), and FORUM (Zeiss, US), following their implementation in an eye hospital for common ophthalmic investigations [visual field, optical coherence tomography (OCT) of retinal nerve fiber layer and macula, and fluorescein/indocyanine green angiography (FA/ICG)]. An online survey was distributed among ophthalmologists in a single center. Primary outcome included comparison of PACS with paper-based system. Secondary outcomes included pattern of use and comparison of different PACS platforms. Survey response rate was 28/37 (75.7%). Images were most commonly accessed through ePR (median: 80% of time, interquartile range: 50 to 90%).All systems scored highly in information display items (median scores ≥7.5 out of 10) and in reducing patient identification error in investigation filing and retrieval during consultation compared to paper (score ≥7.0). However, ePR was inferior to paper in "facilitating comparison with previous results" in all investigation types (scores 3.0 to 4.5). ePR scored significantly higher in all system quality items than HEYEX ( P < 0.001) and FORUM ( P < 0.022), except login response time ( P = 0.081). HEYEX scored significantly higher among vitreoretinaluveitis members (VRU) for information quality items for OCT macula and FA/ICG [VRU: 10.0 (8.0 to 10.0), non-VRU: 8.0 (6.75 to 9.25), P = 0.042]. Overall feedback for PACS among ophthalmologists was positive, with limitations of inefficiency in use of information, for example, comparison with previous results. Subspecialty played an important role in evaluating PACS.

Reducing Injection-Related Safety Events in Retina Clinics.

PurposeAt the Kellogg Eye Center, we identified a series of injection-related patient safety events that led to a systematic review and redesign of our intravitreal injection protocol. The objective was to reduce injection-related patient safety events to zero.MethodsA retroactive review, using the Healthcare Failure Mode and Effect Analysis model as a guide, was performed on our process for delivering intravitreal injections to identify potential failure modes and their impact.ResultsThe total number of injection-related safety events was 1 in 2017 and 16 in 2018 at baseline. Potential vulnerabilities identified included errors in communication, patient identification, clinical documentation, and medication orders. The injection protocol was redesigned. After implementation, there were zero injection-related safety events in all Kellogg Eye Center Retina clinics for the subsequent 18-month follow-up period.ConclusionIt is possible to redesign and implement an intravitreal injection protocol to reduce the rate of safety events in a large academic eye center.

Safety and Feasibility of Home Transfusions in Pediatric Palliative Care: A Preliminary Report

BackgroundWhile hematological symptoms are considered difficult to manage in a Pediatric Palliative Care setting, home may still represent a safe and convenient place for transfusions in patients with advanced malignancy or chronic conditions. This research focuses on the safety and feasibility of a home transfusion program. MethodsThis is a case series of patients between 0 and 18 years diagnosed with advanced malignancy or incurable chronic conditions and eligible to Pediatric Palliative Care who received home platelet or packed red cell transfusions. For all patients, we recorded adverse events such as acute hemolytic reactions, allergic reactions, or any emergency condition requiring hospital admission, equipment failure, blood product transport or storage errors, errors in patient identification, and personnel safety issues. We explored parental satisfaction with a Likert-type questionnaire and short open questions. ResultsWe reviewed 101 transfusion procedures for six patients in Pediatric Palliative Care performed by the Regional Pediatric Palliative Care network between 2014 and 2020. We did not report any adverse effects. Families reported satisfaction and a sense of safety and positively evaluated the opportunity of having transfusion at home to minimize the disruption in everyday life. The cost analysis resulted in a consistent saving for the Regional Health System. ConclusionThis study supports the safety and feasibility of home transfusion in Pediatric Palliative Care.

Interventions to Reduce Patient Identification Errors in the Hospital Setting: A Systematic Review

Background: Patient identification is considered as a fundamental part of the care process and a relevant resource for safety practices in hospital settings. Objective: We aimed to review the literature on interventions to reduce patient identification errors in hospital settings. Methods: A systematic review of effectiveness using The Joanna Briggs Institute (JBI) methodology was conducted. A three-step search strategy was utilised to explore primary research published up to March 2020 in English, Spanish, and Portuguese across eight databases. Grey literature was also assessed. The titles and abstracts of the studies were screened for assessment of the inclusion criteria. Two reviewers independently appraised the full text of the selected studies and extracted data using standardised tools from JBI. Due to the heterogeneity of studies and insufficient data for statistical pooling, meta-analysis was not feasible. Therefore, the results were synthesised narratively. Results: Twelve studies met the review criteria; all were rated at a moderate risk of bias and four different groups of interventions were identified: educational staff interventions alone and those combined with a partnership with families and patients through education; and information technology interventions alone, and combined with an educational staff strategy. Although most studies showed a statistically significant reduction in patient identification errors, the overall quality of the evidence was considered very low. Conclusion: High-quality research is needed to understand the real impact of interventions to reduce patient identification errors. Nurses should recognise the importance of patient identification practices as a part of their overall commitment to improving patient safety. PROSPERO Registration Number: CRD42018085236

Safety and family satisfaction of a home-delivered chemotherapy program for children with cancer

BackgroundHome chemotherapy programs for children with cancer are safe and feasible, and their impact on the quality of life has been reported in different countries. A home chemotherapy program was implemented between 2011 and 2019 in an Italian region. This pilot study investigates its safety and feasibility, along with parental satisfaction.MethodsPatients between 0 and 18 years diagnosed with malignancy were included. Deceased patients and patients whose families moved abroad or interrupted contact with the service were excluded. Adverse events comprised immediate deterioration of the patient’s condition, equipment failure, errors in drug storage, dose or patient identification and personnel safety issues. Parental satisfaction was explored through an email survey of 32 Likert-type and short open questions.ResultsThirty-five patients received 419 doses of intravenous chemotherapy at home (cytarabine, vincristine, vinblastine). No adverse events were reported. Twenty-three families out of 25 eligible completed the survey. Most reported being “very satisfied” with the possibility of maintaining a work/domestic routine and reducing time and financial burden of hospital access. Most were “very satisfied” with the opportunity for their child of being less troubled by the treatment. Besides, most reported being “very satisfied” with the chance for healthy siblings of maintaining their routine and coping with their brother/sister’s disease. Most perceived the program as safe. All families recommended extending the program to all children in the region.ConclusionsThis first Italian study supports home chemotherapy as safe and effective, positively influencing the quality of life for children and their families.