Registration-Associated Patient Misidentification in an Academic Medical Center: Causes and Corrections
Registration-Associated Patient Misidentification in an Academic Medical Center: Causes and Corrections
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DOI：
10.1016/s1553-7250(07)33004-3
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发表时间：
2007-01-01
影响因子：
2.3
通讯作者：
Wassilchalk, Daniel M.
中科院分区：
文献类型：
--
作者：
Bittle, Mark J.;Charache, Patricia;Wassilchalk, Daniel M.
背景资料：正确的病人识别是一个重要因素，影响病人的安全，在任何医疗机构。方法：一个跨学科的团队，使用三个计划，做研究，行为（PDSA）周期，审查了登记过程中的错误造成的病人误认的发生率。回顾性和前瞻性的数据收集，以确定发病率之间的住院和门诊patients.Results：登记相关的患者误认错误发生7至15次，每月。信息系统缺陷、培训不足和缺乏单一的患者总索引是确定的根本原因。三个PDSA周期后，登记相关的患者错误识别错误的发生率下降住院患者（80.5%），但增加门诊患者（30.2%）。讨论：通过迭代过程中隐含的PDSA周期，登记相关的患者错误识别错误的建立约翰霍普金斯医院的患者显着减少。为其他组织提供了一份清单，以评估其对登记相关患者错误识别错误的脆弱性。例如，该清单建议各组织努力制定单一的病人总索引，并将登记系统的使用权限制在受过适当培训和有业绩预期的工作人员。
Background: Proper patient identification is a major factor affecting patient safety in any health care organization.Methods: An interdisciplinary team, using three Plan-Do-Study-Act (PDSA) cycles, reviewed the incidence of patient misidentifications resulting from registration process errors. Retrospective and prospective data were collected to determine the incidence among inpatients and outpatients.Results: Registration-associated patient misidentification errors occurred 7 to 15 times per month. Information systems deficiencies, inadequate training, and the lack of a single master patient index were among the root causes identified. After three PDSA cycles, the incidence rate for registration-associated patient misidentification errors declined for inpatients (80.5%) but increased for outpatients (30.2%).Discussion: Through an iterative process as implied in the PDSA cycle, registration-associated patient misidentification errors for established Johns Hopkins Hospital patients were dramatically reduced. A checklist is provided for other organizations to assess their vulnerability to registration-associated patient misidentification errors. The checklist suggests, for example, that organizations strive to develop a single master patient index and limit access to registration systems to staff with proper training and performance expectations.