205-1188 / Improvement Approach to Preventing Identification Errors in an Emergency Unit

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Hospital Universitario de Getafe


Patient safety system
Quality improvement project
Patient identification
Implementation of Patient Safety initiatives / Activities
GOP Description
Implementation level
Clinical settings
This practice is implanted in the Emergency General area of Hospital Universitario de Getafe.
Reduce the occurrence of adverse effects due to identification errors of patient in the Emergency Department.
All patients attended in the Hospital Emergency Department.
Creating a security group of 10 people made up of workers from all occupational categories working in the Emergency Department. Analysis of incidents detected during the activity, either by direct observation of it, or by information obtained through the incident reporting system of the hospital. Pareto analysis of the most frequent incidents. Using a grill type of incident prioritization, address by importance (consequences for the patient) and frequency of occurrence. Analysis of possible solutions, through brainstorming. Defining the procedure to implement the solution. Definition of the indicator to verify the effectiveness of the measure. Definition of the technical instruction of action. Dissemination sessions among all workers of Emergency Department. Analysis of the effectiveness of the implanted measure.
Timeframe implementation
3 months for the procedure definition of action procedure and five months to implement the wristbands.
Implementation tools available
Incident analysis. Pareto analysis. Grill prioritization. Meetings for the dissemination of the action. Performance indicators.
Implementation cost
Wristbands: € 7,000 / year.
Printer 350 €.
Method used to measure the results
The following indicators are defined:
• Number of patients seen in the Emergency Department without wristband x 100 / all patients seen in the Emergency Department (goal: < 0.5%).
• Number of incidents of misidentification of the patient after the implementation of the measure x 100 / all patients seen in the Emergency (Target: 0).
• Number of adverse effects of patient misidentification following the introduction of the measure of prevention (Target: 0).
During 2013 and 2014, 20% of detected incidents involving patients were related with patient misidentification. They are the most frequent incidents in the Emergency Department.

Technical procedure for the use of wristbands was finished in October 2014. During November and December, workers were trained. From January 2015 wristbands are used for patient identification.

Between January 2015 and October 2015 about 58000 patients were attended in the Emergency Dept. Fewer than 0.1% had not wristbands. During 2015 there were no incidents due to misidentification.

Analysis of the results
The corrective action implemented in the Emergency Department has been effective for the intended purpose. Patient safety has been improved. At present patient identification is carried out asking the patient name and surname and checking these data with the ones showed in the wristband.Although the cost of the practice is relatively high, the savings from the reduction of erroneous treatments or duplicated diagnostic tests has been higher than the cost of the implementation, especially in the case of radiological tests.
Implementation barriers
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Other information
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201511260854258497_406_GOP_IT 03-10.doc