Patient identification in healthcare organizations: an emerging debate

Abstracts

O processo de identificação do paciente é essencial para garantir a segurança e a qualidade da assistência nas instituições de saúde. O emprego de pulseira para identificação é uma prática usual. Contudo, fatores culturais, organizacionais, materiais e humanos concorrem para sua não conformidade, induzindo a erros ou acarretando eventos adversos. Este artigo teve como objetivos destacar os elementos constituintes do processo de identificação do paciente por meio de pulseiras e refletir acerca da implementação desse processo nas instituições hospitalares. Adotaram-se referenciais teóricos e normatizações de organizações e órgãos acreditadores que discutem a temática da segurança no âmbito hospitalar, bem como as iniciativas destinadas à identificação segura do paciente. Conclui-se que a identificação do paciente por meio de pulseira é uma prática recomendada internacionalmente, porém há lacunas no que tange à instituição de protocolos, à execução efetiva e à avaliação do processo para subsidiar ações gerenciais e assistências.

Qualidade da assistência à saúde; Segurança do paciente; Avaliação em saúde; Enfermagem

REFLEXION ARTICLE

Patient identification in healthcare organizations: an emerging debate

Identificación del paciente en las organizaciones de salud: una reflexión emergente

Terezinha Hideco Tase^I; Daniela Campos de Andrade Lourenção^II; Suzana Maria Bianchini^III; Daisy Maria Rizatto Tronchin^IV

^IObstetrics nurse, Doctorate degree student of the Graduate Programme in Nursing Management at the School of Nursing of the University of São Paulo, Master´s degree in Obstetrics and Neonatal Nursing. Head Nurse of the Obstetrics Clinic at the Clinicas Hospital, Faculty of Medicine of the University of São Paulo. São Paulo/SP/Brazil

^IINurse, Doctorate degree student of the Graduate Programme in Nursing Management at the School of Nursing of the University of São Paulo, Master´s degree in Work Health and Management. Capes Scholar. São Paulo/SP/Brazil

^IIINurse, Doctorate degree student of the Graduate Programme in Nursing Management at the School of Nursing of the University of São Paulo, Master´s degree in Nursing. Coordinator of Healthcare Practices of the Oswaldo Cruz German Hospital. São Paulo/SP/Brazil

^IVNurse, Habilitated Professor, Department of Orientation, School of Nursing of the University of São Paulo. São Paulo/SP/Brazil

Author's address

ABSTRACT

The patient identification process is essential to ensure safety and quality of assistance in healthcare institutions. The use of a wristband for identification is common practice, although cultural, organization, material and human factors cause non-conformity resulting in errors or adverse events. The aim of this article is to highlight constituent elements of the patient identification process by means of wristbands and discuss topics related to the implementation of this process in hospitals. This study was based on theoretic references and standardizations of accrediting organizations and bodies that debate security in the hospital environment and incentives for safe patient identification. It was concluded that patient identification by means of wristbands is recommended internationally although there are loopholes in relation to protocol, effective execution and evaluation of the process to support management and healthcare actions.

Descriptors: Quality healthcare. Patient safety. Healthcare evaluation. Nursing.

RESUMEN

El proceso de identificación del paciente es esencial para garantizarla seguridad y la calidad de la atención en las instituciones de salud. El uso de la pulsera de identificación es una práctica común; sin embargo, factores culturales, organizativos, materiales y humanos compiten por su no conformidad, induciendo a errores o eventos adversos. Este trabajo tuvo como objetivo resaltar los elementos constituyentes del proceso de identificación del paciente por medio de las pulseras y reflexionar acerca de la implementación de este proceso en los hospitales. Hemos adoptado marcos teóricos y normas de organizaciones y organismos acreditadores que discuten la temática de seguridad en los hospitales, así como las iniciativas para la identificación segura del paciente. Se concluye que la pulsera de identificación del paciente es una práctica internacionalmente recomendada, pero hay brechas respecto al establecimiento de protocolos, la implementación eficaz y la evaluación del proceso para apoyar las acciones de gestión y asistencia.

Descriptores: Calidad de la atención de salud. Seguridad del paciente. Evaluación en Salud. Enfermería.

INTRODUCTION

The topic of patient safety is intrinsically related to providing quality healthcare services and has been widely acknowledged and discussed by healthcare service providers, trade associations and government entities.

Two milestones can be considered decisive for the advancement of debates and questioning on this topic: the first occurred in 2004, when the World Health Organization (WHO) established the World Alliance for Patient Safety that targeted socialization of knowledge and solutions by means of international programmes and incentives with recommendations that ensured patient safety around the world; and, in 2007, when the "World Health Organization's Collaborating Centre for Patient Safety Solutions launched the "Nine Patient Safety Solutions" programme to reduce errors in the healthcare system, resulting in the redesign of care processes to prevent unavoidable human errors, including incorrect patient identification ^(1-2).

We also verified participation of healthcare accreditation organizations, which reaffirms patient safety as the first goal to accomplish by these services. A good example, the Joint Commission International (JCI), demands compliance with international safety standards that are categorized to correctly identify patients, make communication effective, improve high-surveillance medication safety, ensure surgery with the correct intervention locations and patients, reduce risk of infection associated to healthcare and reduce the risk of injuries to patients caused by falling⁽³⁾.

In 2006, the National Accreditation Organization (ONA) added risk management to its level 1, requiring that evaluation criteria meet formal, technical and structural patient safety standards according to existing laws ⁽⁴⁾.

In Brazil, based on the same WHO objectives and an initiative of the Pan-American Health Organization, the Brazilian Nursing and Patient Safety Network was established (REBRAENSP) with the key purpose of promoting and consolidating the culture of patient safety. In a joint action with the Regional Nursing Advisory Council of the state of São Paulo (COREN-SP), it created 10 steps for patient safety based on the main aspects of nursing services that could be implemented in several healthcare environments for the purpose of ensuring safe health service provision ⁽⁵⁾.

Patient safety is considered one of the most relevant solutions presented by these organizations. If conducted correctly, it can prevent errors related to health services provided by the professional healthcare team at all levels.

In view of the elements that make up the "patient safety" construct and the complexity of work processes in hospitals, we verified that patient identification is all-inclusive and of multidisciplinary responsibility, as it involves aspects of structure, work process designs, organizational culture, professional practice and user participation.

Non-conformities of patient identification have been identified as a cause for concern in healthcare services^(1,6,7,9), revealing that incorrect identification leads to a series of adverse events or errors that involve drug administration and blood components, procedures, surgeries and laboratory and radiological testing, the handing over of newly born babies to the wrong families at discharge and during breastfeeding ⁽¹⁾.

Other factors related to identification errors are switched numbers in hospital records, use of the wrong labels or with incorrect, incomplete or illegible data and namesakes.

At the end of 2005, after receiving 236 reports on omissions and errors of patient identification, the National Patient Safety Agency (NPSA)published specific recommendations on the use of identification wristbands that had to be implemented within six months in the United Kingdom⁽⁸⁾. According to the recommendations, all patients had to use the wristbands, unless unauthorized by the patients or for clinical reasons, with subsequent status registration in patient medical records.

The use of patient wristbands reduces error rates, but any incorrect or imprecise data on the wristbands can lead to confusion and increase the risk of adverse events ⁽⁹⁾.

In spite of measures to standardize and promote knowledge of healthcare professionals and the high incidence of adverse events and errors, patient identification has not been acknowledged as essential for the provision of safe care, research and legitimacy of the care process by the multidisciplinary team.

Another topic related to guidelines and protocols that deserves attention is education and awareness actions for healthcare professionals that enables them to value unequivocal patient identification, regardless of hospital stay time or clinical conditions, and create awareness in users in terms of demanding the use of wristbands and promoting this practice within society. We observed that during daily work activities, the practice of checking patient wristbands is neglected by healthcare professionals, especially for patients with long-term hospitalization.

In view of the observations presented above, the aim of this theoretical-reflexive article is to highlight constituent elements of the patient identification process by means of wristbands and debate the implementation of this process in hospitals.

PATIENT IDENTIFICATION PROCESSES BY MEANS OF WRISTBANDS

Specifically, in terms of patient identification, the WHO suggests that healthcare institutions should create and execute programmes and protocols that focus on healthcare worker responsibility to correctly identify patients, standardize wristband use and the inclusion on wristbands of at least two qualifying elements, contraindicating bed or room numbers. It also promotes the incorporation of continued education of healthcare professionals based on monitoring the patient identification process and the effective participation of users and their family members in this process ⁽¹⁾.

The protocol published and implemented in the United Kingdom by the National Health Service (NHS)and the NPSA establishes that all hospitalized patients should be identified with wristbands known as identification "tags" or "bracelets". This document also stipulates the following requirements: appropriate size (newborn babies, obese patients, clinical conditions), comfort (anti-allergic, flexible, waterproof and washable material), durability (easy-cleaning, resistant to body fluids, soaps and alcohol-based solutions), printing technique and applicability (electronically generated and printed, easy to read, enough room to print full and unequivocal identifiers), colour (white), text (black), identifiers/qualifiers (full name – surname first with capital letter, date of birth and file number in the national health system)⁽¹⁰⁾.

Furthermore, the protocol establishes adequacy of identifiers and placement of the wristbands in the case of patients with special needs, such as visual impairments, clinical conditions and serious malformations that prevent fastening of the wristband on the patient's limbs ^(8,10). Other technologies are also indicated, such as bar codes, radio frequency and biometry, associated to use of the wristband to record verification of patient identification. ^(8,10).

In Brazil, the obligatory identification of patients originated in the inside of maternity wards and hospitals at the start of 1990 based on Law 8069, Article Ten of the Statute of Children and Adolescents, by means of foot and finger print records ⁽¹²⁾. This identification method had been used since 1903, mostly in Brazilian maternity hospitals ⁽¹²⁾, but was questioned due to illegibility, imprecision and quality of the material used for printing ⁽¹³⁾. In 1933, a second element was proposed to identify the mother and newborn baby by means of a wristband (cord or aluminium plate) with a number that indicated the sequential order of birth ⁽¹²⁾.

Another relevant point is related to strategies suggested by the WHO that involve the culture of safety in healthcare services in view of the stigma associated to use of the wristband, inconsistencies and falsification of birth data and healthcare plans and lack of familiarity of professionals with the names of individuals in a given culture, which can prevent patients from being checked or from speaking out⁽¹⁾.

In the hospital environment, the wristband is the best resource for patient identification insofar as it is based on protocol and used efficiently by healthcare professionals ^(8-11).

A study conducted in a private maternity hospital in the municipality of São Paulo described and evaluated the identification protocol of newborn babies by means of wristbands. Total intended quantity of wristbands was three, containing the following qualifiers: full name of mother, assistance number of mother and baby, type of hospital admission and legible barcode. In the case of newborn babies with special needs, the wristband was fixed to the incubator. Conformity rate of the identification process was 86%, being that conditions of the wristbands had the best results and number of wristbands showed the worst conformity rates ⁽⁷⁾.

These results support the affirmation that quality of healthcare services must permeate organizational policies and goals that target assistance based on safety and the satisfaction of users and healthcare workers ⁽¹⁴⁾.

FINAL CONSIDERATIONS

Although debates and initiatives to ensure safety are being developed and gaining significant ground, there are still loopholes in relation to effective implementation and monitoring of patient identification protocols on behalf of healthcare professionals, service managers, trade associations and the actual users. Consequently, there is a need to consider involvement and responsibility of healthcare professionals and users as a constitutive element for the identification process to be effective in healthcare institutions.

Another important point to consider is the debate on the culture of safety that involves management and workers. This debate must also take into account the complexity of the identification process and its repercussions on health of the user, image of the institution and the professionals involved.

In addition to standardization of activities, we emphasize the importance of implementing service quality control that considers structure and processes, and measuring and promoting results to minimize risks caused by incorrect patient identification that mostly result in health issues portrayed by morbidities or death.

REFERENCES

• 1 World Health Organization. Joint Comission Resources. Joint Comission International. Patient Safety Solutions. Solution 2: patient identification [Internet]. 2007 [cited 2011 Jan 11];1:8-11. Available from: http://www.jointcommissioninternational.org/WHO-Collaborating-Centre-for-Patient-Safety-Solutions/
• 2 Donaldson LJ, Fletcher MG. The WHO World Alliance for Patient Safety: towards the years of living less dangerousl. Med J Aust. 2006;184(10 Suppl):S69-72.
• 3 Joint Commission International. Padrões de acreditação da Joint Commission International para hospitais. 4Ş ed. Oakbrook Terrace: JCI, 2011.
• 4 Organização Nacional de Acreditação. Manual das Organizações Prestadoras de Serviços Hospitalares. Brasília (DF); 2006.
• 5 Conselho Regional de Enfermagem de São Paulo (COREN-SP), Rede Brasileira de Enfermagem e Segurança do Paciente (REBRAENSP). 10 passos para a segurança do paciente [Internet]. São Paulo: COREN-SP; 2010 [citado 20 Mar 2011]. Disponível em: http//www.coren-sp.gov.br.inter.coren-sp.gov.br/sites/default/files/10_passos_segurança_paciente.pdf
• 6 Askeland RW, McGrane SP, Reifert DR, Kemp JD. Enhancing transfusion safety with an innovative Bar-Code-Based tracking system. Healthc Q. 2009;12(Special):85-9.
• 7 Quadrado ERS, Tronchin DMR. Avaliação do protocolo de identificação do neonato de um hospital privado. Rev Latinoam Enferm [Internet]. 2012 [citado 20 Nov 2012.]; 20(4):[08 telas]. Disponível em: http://www.scielo.br/scielo.php?pid=S0104-11692012000400005&script=sci_arttext&tlng=PT
• 8 Sevdalis N. Design and specification of patient wristbands: evidence from existing literature, NPSA-facilitated workshop, and a NHS trust survey [Internet]. [London]: National Patient Safety Agency; 2007 [cited 2012 Mar 7];[20]. Available from: http:www.npsa.nhs.uk./2763_wristband_specificat~ iew_sevdalis_pdf
• 9 Perry DC, Scott SJ. Identifying patient in hospital: are more adverse events waiting to happen? Qual Saf Health Care. 2007;16(2):160.
• 10 National Patient Safety Agency (NPSA). Wristbands for hospital inpatients improves safety. Safer Practice Notice [Internet]. 2005 Nov 22 [cited 2010 Mar 20]. Available from: http:www.npsa.nhs.uk/site/media/documents/1440_safer_Patient_identification_SPN.pdf
• 11 Ministério da Saúde (BR). Estatuto da Criança e do Adolescente. 3Ş ed. Brasília (DF): Editora do Ministério da Saúde; 2006.
• 12 Quintanilha RC. Da identificação do recém-nascido [tese]. São Paulo (SP): Faculdade de Medicina, Universidade de São Paulo; 1933.
• 13 Weingaertner D. Aquisição de impressões plantares em formato digital para a identificação biométrica de recém-nascidos [tese]. Curitiba (PR): Universidade Federal do Paraná; 2007.
• 14 Tronchin DMR, Melleiro MM, Kurcgant P, Garcia AN, Garzin ACA. Subsídios teóricos para a construção e implantação de indicadores de qualidade em saúde. Rev Gaúcha Enferm. 2009;30(3):542-6.

Publication Dates

• Publication in this collection
  02 Dec 2013
• Date of issue
  Sept 2013

History

• Received
  19 Jan 2013
• Accepted
  24 May 2013