Patient Misidentification Events in the Veterans Health Administration: A Comprehensive Review in the Context of High-Reliability Health Care.
Journal
Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393
Informations de publication
Date de publication:
01 Jan 2022
01 Jan 2022
Historique:
pubmed:
15
9
2020
medline:
24
2
2022
entrez:
14
9
2020
Statut:
ppublish
Résumé
The Veterans Health Administration maintains national patient safety event reporting and root cause analysis (RCA) databases. These were reviewed to understand the prevalence of and provide insight into patient misidentification. The results were compared with a high-reliability health care framework. We reviewed patient safety reports and RCA reports to identify and categorize patient identification-related events from October 1, 2016, to September 30, 2018. We analyzed 3232 patient safety reports and 67 RCAs, aggregated the findings, and compared them against The Joint Commission's High Reliability Health Care Maturity Model. Patient misidentification occurred in both inpatient and outpatient settings, for which the ratio of adverse events to close calls was similar. The ratio of adverse events to close calls varied for specific care areas. The most common RCA event characteristic was Two identifiers not used (39%). The most common failure mode was Procedure performed on wrong patient (31%). Issues related to policy and processes accounted for 42% of the root causes. Actions taken were primarily related to policy, process, and staff training/education (56%); these actions were rated as effective by the reporting facilities. Patient misidentification is prevalent in both the inpatient and outpatient settings. However, specific care areas reported more close calls, an indicator of good safety culture. There were associations between policy and process issues, consistent use of 2 identifiers, and misidentification events. This review provides insight from the Veterans Health Administration national databases that health care institutions can use to improve their systems.
Identifiants
pubmed: 32925569
pii: 01209203-202201000-00048
doi: 10.1097/PTS.0000000000000767
doi:
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
e290-e296Informations de copyright
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The authors disclose no conflict of interest.
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