903 / Patient Identification: A Quality Improvement Process for Patient Safety

SPAIN
Classification of the PSP
Type of Patient Safety Practice Potentially Safe
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Patient identification
Diagnostics There is no specified text here
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
 
The practice aims at correcting patient identification errors. These errors pose a great number of risk factors to cause an avoidable adverse event for the health of the patient.
Accurate patient and specimen identification is crucial; misidentification can have numerous consequences, such as an invasive procedure performed on the wrong patient, a result reported for the wrong patient, and missed or delayed diagnoses. Worst-case scenarios include missed cancer, and hemolytic transfusion reactions.
Patient identification and his/her samples refer to the correct initial identification of a patient and the absolute linking of all specimens to that patient throughout the entire testing process, including collection, analysis, and reporting.
Identification of the patient and his/her samples must be included in the policy and procedures that must be followed in public hospitals to ensure correct patient Identification at all times fron analytical request by the doctor to analytical results.
Description of the Patient Safety Practice
 
OBJECTIVE:
Performance improvement strategies for the biological identification of the patient and patient samples.
Another objective is to design the policy and protocol for the health professionals involved and that request patient identification and/or samples as part of their clinical practice.
A third objective is to elaborate a Norm of Security of Identification of patient and his/her samples
A fourth objective is to evaluate Indicators before and after the implementation of these measures of improvement

MATERIAL:
The study was performed at Hospital Clínico, Madrid, Spain, a 978-bed academic medical center. The clinical laboratory is integrated within the hospital. This Laboratory has urgent and programmed activity 24 hours a day. In 2013, nearly 350.000 analitycal requests and blood collections were done.

METHOD:
1o To Design all the Process and to elaborate a Protocol to be followed by all the health professionals involved in the Patient Identification and his/her samples.

2o To elaborate a Norm of Security (Procedure) of Identification of the patient and his/her samples. This Norm of Security must be followed by health professionales.

3o To Evaluate Indicators before and after the implementation of these measures of improvement.

4 To involve the patient in his/her identification


RESULTS:
Before implementation
•    Of the 3,817 Emergency analitycal requests, 5.7% of them presented patient identification error and it was impossible to identify the patient in 32,9%

•     Of the 5821 analitycal requests from Hospitalization inpatients 6,9 % presented patient identification error and 21.5% were cumplimented without patient dentification label

After implementation

•    We analyzed 14,191 analitycal requests: Emergengy (3576), and Hospitalization (10,615)
•    We applied the same indicators used before implementation of improvement measures.
•    We observed a signifivative decrease of % of incidences after the processes improvement implementation (5,70 % versus 0,97% in emergencies) (21,5% versus 2.09% in hospitalization). In cases in which the requests were identified manually, % in which it was not possible to be identified of unequivocal form the patient did not present/display significant

CONCLUSIONS

All patients must be correctly identified at the time of registration/admission and throught their hospital stay. Health care providers should have guidelines in every place on how the patient must be identified.

The patient must be consistently and accurately identified before any phlebotomy or specimen collection. Once collected, all specimens must be labeled with two positive identifiers in the presence of the patient.
The applied strategies of improvement have demonstrated to be effective in the improvement of the identification of the patient in the analytical requests. However, we must continue working in this strategy, fomenting the culture of security of all the involved professionals and trying to reach the objective of 100% of the requests correclty identified

BIBLIOGRAPHY
•E.E. MORENO CAMPOY, F. J. MERIDA DE LA TORRE, A. BUNO SOTO , M. CABALLERO Ruíz, M.A. Cuadrado Cenzual, Fernández Nogueria, A.M. García Raja, M. Ibarz Escuer, L. Vázquez Mourin Comité Científico “Seguridad del Paciente Documento Básico”. G. Trabajo Seguridad del Paciente. Ed. SEQC ISBN: 2013-5750 2011

•A ALGUACIL PAU , J CABELLO CARRO , E CASANOVA, CUADRADO CENZUAL MA , et al “Identificación de Paciente y sus Muestras Biológicas” Herramientas Corporativas en Seguridad Clínica . Las Instrucciones de Seguridad del Hospital Clínico San Carlos de Madrid Volumen I Unidad Funcional de Riesgos Sanitarios Ed. HCSC ISBN: 978/84/694/5231/8

•ALVAREZ C, ORTEGA I, CUADRADO-CENZUAL MA: La seguridad del Paciente en el Laboratorio Clinico. Implantación de un Protocolo de Identificación Inequívoca de Paciente. ISSN-e 1888-4008Rev Labo CLin. 2012;05:3-9

Attachment of relevant written information and/or photos, as appropriate
2014022101194922002_WP4_FIG1.docx
There is no specified text here
There is no specified text here
There is no specified text here
Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, partly
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Not known
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Quantitative
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
2014022101240412002_WP4_LABCLIN-S-11-00062[1].pdf
Health care context where the Patient Safety Practices was implemented
 
Primary care
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Not known
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Physicians
Nurses
Clinical manager
Quality manager
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
No
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
There is no specified text here
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users' level of involvement
There is no specified text here
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Not known
List of sources where public information is accessible
There is no specified text here
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
Not known or not relevant
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Yes
Description of used incentives, if any.
FORMATION AND COMUNNICATION
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: MARIA ANGELES CUADRADO CENZUAL
Country: SPAIN
Organisation: HOSPITAL CLINICO SAN CARLOS . MADRID
E-mail: mariaangeles.cuadrado@salud.madrid.org
Phone: There is no specified text here
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