Registration-Associated Patient Misidentification in an Academic Medical Center: Causes and Corrections
| Autor: | Daniel M. Wassilchalk, Patricia Charache, Mark J. Bittle |
|---|---|
| Rok vydání: | 2007 |
| Předmět: |
Patient Identification Systems
medicine.medical_specialty Quality Assurance Health Care Leadership and Management MEDLINE Patient safety Health care medicine Humans Prospective Studies Prospective cohort study education Psychiatry Master patient index Academic Medical Centers education.field_of_study Medical Errors business.industry Incidence (epidemiology) Process Assessment Health Care medicine.disease Checklist Interdisciplinary Communication Medical emergency business PDCA |
| Zdroj: | The Joint Commission Journal on Quality and Patient Safety. 33:25-33 |
| ISSN: | 1553-7250 |
| Popis: | Article-at-a-Glance 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. |
| Databáze: | OpenAIRE |
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