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Intervention efficacy for eliminating patient misidentification using step-by-step problem-solving procedures to
Tatsuya Fukami1, Masakazu Uemura1, Mineko Terai1
1Department of Patient Safety, Nagoya University Hospital, Nagoya, Japan.
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.
Insights
Implementing a step-by-step problem-solving method significantly reduced patient misidentification incidents, including adverse events. This systematic approach is crucial for enhancing patient safety and preventing errors in healthcare settings.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety Research
- Medical Error Prevention
Background:
- Patient misidentification incidents, particularly those resulting in adverse events (Level 2 and above), pose a significant threat to patient safety.
- An increasing trend in misidentification reports highlighted the urgent need for effective intervention strategies.
Purpose of the Study:
- To evaluate the efficacy of a structured, step-by-step problem-solving method in reducing patient misidentification incidents.
- To decrease the occurrence of Level 2 and over patient misidentification events within a healthcare setting.
Main Methods:
- A comprehensive eight-step problem-solving process was employed, analyzing incident reports to identify root causes.
- Interventions included standardizing patient identification procedures and disseminating instructional videos to all staff.
- A specific target of a 20% decrease in Level 2 and over incidents was set.
Main Results:
- The study identified discrepancies in patient identification procedures as the primary cause of misidentification.
- Standardizing the identification process led to an initial 10% reduction in misidentification.
- A significant 18% reduction in Level 2 and over patient misidentification was achieved compared to the previous year.
Conclusions:
- A systematic, step-by-step problem-solving approach is effective in reducing patient misidentification incidents and improving patient safety.
- Continued efforts and adherence to a robust patient identification policy are essential for sustained error reduction.
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