Use of identification wristbands among patients receiving inpatient treatment in a teaching hospital

OBJECTIVE: to evaluate the use of identification wristbands among patients hospitalized in inpatient units. METHOD: quantitative, descriptive and transversal research, with a sample of 385 patients. Data collection occurred through the observational method through the filling out of a structured questionnaire which aimed to check the presence of the identification wristband and the identifiers used. Descriptive statistics with absolute and relative frequencies was used for analysis. RESULTS: it was obtained that 83.9% of the patients were found to have the correctly identified wristband, 11.9% had a wristband with errors, and 4.2% of the patients were without a wristband. The main nonconformities found on the identification wristbands were incomplete name, different registration numbers, illegibility of the data and problems with the physical integrity of the wristbands. CONCLUSION: the study demonstrated the professionals' engagement in the process of patient identification, evidencing a high rate of conformity of the wristbands. Furthermore, it contributed to identify elements in the use of wristbands which may be improved for a safe identification process.


Introduction
Patient safety has been the focus of discussions over the last decade worldwide. Brazil is part of this mobilization and, since April 2013, has placed emphasis on the actions through the launch of the National Patient Safety Program (PNSP). The program establishes protocols for meeting the international safety guidelines and determines the creation of Patient Safety Nuclei in the health services (1)(2) .
In order to reduce errors and extend the number of safe practices, health institutions are investing in actions which aim for quality of care and seek to spread a culture of safety for the patients, for the professionals, and for the environment. These changes are focused on the six patient safety goals stipulated by the World Health Organization (WHO), goal number one being the correct identification of the patient (3) .
In daily life, it can be observed that the health services adopt different ways of identifying the patients, for example, wristbands, signs on the headboards, stickers on clothes, and identity badges. Since the PNSP was launched, institutions have needed to compatibilize the devices stipulated by the protocol and the patients' wishes. In spite of there existing few studies specifically addressing the issue of patient identification, it is possible to note a worldwide concern in relation to this practice, as it is closely related to any procedures undertaken with the patients, such as the administration of medication, operations, and transfusion of blood or blood products, among others.

Mistakes in identification can originate back
at the moment when the patient is entered in the attendance system. The entering of data with errors, in a computerized record, can compromise the entire care process (4) . The process of patient identification, including the checking of data on the wristband against the patient's records and with the information confirmed by him or her, can be seen as an important stage in the interaction between the patient and the health team.
Errors caused by carelessness can continue to occur if the patients do not have wristbands, or if the wristband does not contain accurate information for identification (5) .
In 2007, the National Patient Safety Agency (NPSA) of England and Wales revealed in a publication that more than one in 10 cases of incompatible care measures notified were related to wristbands. The correct use of wristbands and the definition of standards regarding color, material and identifiers promote safe practice regarding patient identification, which means an additional resource in the combating of the devastating errors which incorrect identification can bring (6) .
Following the provision, by the NPSA, of guidance for safe practice related to identification, it was observed that 98% of the hospitals had developed policies which were consistent with these directives, although 23% reported difficulties in implantation and in adherence by patients and teams (7) .
The identification of the patient has two purposes: firstly, to safely determine the individual as being the legitimate receiver of the treatment or procedure; secondly, to ensure that the procedure to be undertaken is effectively that which the patient needs (8) . In day-today practice, one can perceive that patient identification is a stage of the nursing care which does not receive the appropriate attention, although it can influence the other stages and is essential in order to ensure the quality and safety of the service provided.
Considering the aspects raised regarding the importance of the correct identification of the patient and its relationship with the occurrence of errors in healthcare, and, on the other hand, the extent to which this is little valued in the practice environments, the following research question arose: are the patients using wristbands which ensure their correct identification? As a result, the present study was undertaken with the aim of assessing the use of the wristband among patients hospitalized in inpatient units in a teaching hospital.

Method
This is a study with a quantitative, descriptive and transversal approach, undertaken in a teaching hospital with 841 beds, in Porto Alegre in the state of Río Grande do Sul, Brazil (9) . The data were collected in the clinical, surgical, mother and child and pediatric inpatient units, totaling 19 departments.
The study population was the patients hospitalized in the above-mentioned units. The sample was defined non-probabilistically, with the patients being selected by convenience. In 2011, the hospital obtained a total of 22,112 episodes of inpatient treatment in these units (10) . In order to calculate the proportion of correct use of the identification wristband in such a way as to maximize variance (estimating that 50% would be using the wristband correctly), considering a margin of error of five percentage points and the level of confidence of For the collection of the data, the participants -aged over 18 years old -were requested to read and sign the terms of consent. Specific terms of consent were created for patients who were minors, to be signed by their parents or guardians.

Results
The present study ascertained that of the 385 patients observed, 369 (95.8%) had the wristband, and 16 (4.2%) patients did not have a wristband. Of the patients with the wristband, it is observed that

83.9% (323) were identified in accordance with what is stipulated by the institution's Standard Operating
Procedure (SOP) for patient identification, while 11.9% were not in accordance. The conformities were related to the presence and physical integrity of the wristband, the legibility of the data, the presence of two identifiers -these being the complete name and the number of the hospital records -and to the data found on the wristband being in accordance with the data found in the patient's online hospital records. also seen that in 3 wristbands it was not possible to read some numbers, and that in one wristband there was no registration number.
The color of the wristband was also a variable investigated, the use of 278 (75.3%) white wristbands and 91 (24.7%) orange wristbands, which indicated the presence of some form of allergy, being observed. In some patients, it was observed that their wristbands were covered by anti-allergenic micropore, as they had developed allergies to the material of the wristband. The alternative, to cover the wristband, was found by the nursing team so that the patient would not have to forgo the use of the wristband. In relation to the 16 patients who were without a wristband, 6 (37.5%) cases occurred in the pediatric inpatient unit. The main reason described by the children's parents or guardians was that, when they attached the wristband, the nursing professionals left it too large for the size of the children's forearms, leading to the loss of the wristbands. A further 4 (25%) patients without wristbands were receiving inpatient treatment in the psychiatric unit, it being the case that the patients themselves reported that they had no wristband because they did not want to use them. The 6 (37.5%) remaining patients were receiving inpatient treatment in the adult clinical and surgical inpatient units. On being questioned as to why they had no wristbands, 2 of them responded that they did not want to use them and that they did not even believe that this practice was important, while the other 4 stated that the wristband had been removed by the nursing team in order to place a venous access point, and that the team had forgotten to replace it on the other arm.

Discussion
According to the results presented, 83.9% (323) of the patients were identified in accordance with the requirements described in the institution's nursing SOP. To monitor the proportion of patients using the standardized wristband is one of the practices recommended in the patient identification protocol (2) .
Although the percentage evidenced seems to be an excellent result, the number of individuals identified correctly should be close to 100%, mainly because the identification of the patients is an important stage which precedes the majority of care measures. In another study, the authors recommend that the error rate, relative to wristbands, should be kept at between 0.2% and 0.3% (11) . 71.6% were attributed to absent wristbands, 7.7% to illegible wristbands, 6.8% to wristbands with incorrect information, 9.1% to wristbands with unclearly printed information, 3.7% to wristbands which had conflicting data, and 1.1% in which the wristband was wrong (11) , demonstrating that the problem of the absence and of the illegibility of the wristbands was the most frequent issue. The authors also mentioned that wrong wristbands are easier to correct than absent wristbands, which supports the results of the present study, in which the rate of individuals without a wristband is lower than the rate of individuals with wrong wristbands.  and elaborate systems, but, rather, requires the strengthening of the simple system already in place (11) .
In consonance with this, in one Brazilian study, the authors confirmed that "while the equipment for the use of barcodes can have a high cost, the use of wristbands and the appropriate identification on the bed generate lower costs and, if used effectively, contribute to minimizing the occurrence of the administration of medications to the wrong patients" (13) .
The absence of the wristband and errors in the patient's name and identification number are recognized as the most frequent types of error when one is discussing the checking of patients' wristbands. One study conducted over 45 months indicated that the absence of wristbands is responsible for 50.3% to 100% of the problems found, the name for 0% to 24.6%, and the number for 0% to 25.3% of the errors (14) .
The strategy of implanting wristbands as one of the tools for promoting the care which strives for the patients' safety is configured as a low-cost practice for the institutions, which is easy to install in the health professionals' routine of care.
The fact that the nursing professionals have to write the patients' data on the wristbands is configured  (13) . One recent study ratifies the wide use of wristbands with barcodes and the reduction of the number of errors related to this stage of the care; however, it also considers that the disadvantage of this technology is the cost of its implantation (15) .
It is calculated that the costs of implanting barcode technology in wristbands is between US$200,000 and US$1 million, depending on the size of the hospital (15) .
In comparison, a study undertaken in the United States indicates that 1% to 2% of patients receiving inpatient treatment suffer harm resulting from medication errors, and describe that each error results in an additional cost of US$4,700 to US$5000, without taking into account the legal costs (16) . In analyzing these data, and those from another study, which described that of 24,382 errors recorded, 2900 were related to patient identification, one can calculate a cost of over US$ 13 million in order to fix such errors (6) . In this perspective of analysis, this technology's implantation would represent a lower cost for the institutions, and safer care.
It is appropriate to warn that, even with the incorporation of the technology, it is necessary for the professionals to rigorously follow the recommendations to scan the barcodes on the patient's wristband and on the medication to be administered, in order to confer safety on the process. A study undertaken in hospitals reveals that, sometimes, these care steps are not followed due to the wristbands being damaged (wet from body fluids, crumpled or torn) and to the data being illegible, or even inaccessible due to the patient being asleep (17) .
The results evidence that the largest number of and that in 63.67% of cases, these patients were identified in some way (18) . Another study reinforces the need for greater attention regarding this group due to the fact that pediatric patients have barriers to verbal communication, requiring the active participation of family members in confirming identification (19) . The wristband, for pediatric use, must have a minimum size so as to ensure comfort and safety for this special group of patients (2) .
In relation to the psychiatric inpatient unit, the single reason provided by the patients themselves referent to the absence of the wristband was that they had no interest in using the wristbands stipulated by the hospital. In the search for references which might help in understanding this result, a single study was found which raised data on psychiatric units. In it, the authors present that of 14 patients observed, 14 did not have the wristbands -that is, 100% of the patientsand that, when the nurse responsible for the unit was questioned, she stated that the reason for this result was the small number of beds, which led the team to know all the patients receiving inpatient treatment (20) .
Attention is drawn to the fact that even in units with few beds, one must take into consideration that allergy was red (21) .
A recent publication emphasizes that the absence of standardization can confuse those professionals who work in more than one institution, in relation to the color of the wristband * . Thus, in Pennsylvania (USA), the standardized use of colors for indicating the risk of the occurrence of safety events was proposed (22) .
In relation to this issue, the Brazilian Network for Nursing and Patient Safety -Rio Grande do Sul Branch (REBRAENSP -RS) held discussions on the * In Brazil, due to low salaries, it is very common for nurses to work a second shift in another department or institution. Translator's note. standardization of wristband colors, with the aim of defining the most appropriate color for indicating allergy.
After the reports from nurses from different institutions, it was ascertained that the colors used most were orange and red. In a recent publication, the Network chose to suggest only the use of the color red, in order to reduce still further the scope for possible mistakes (23) .
Adopting improved practices and new working routines in the health institutions is a complex process, due to the time the teams take to adapt to new policies.
The already-established routines ensure a comfort zone for the professionals, while the proposal to reconfigure the actions can trigger feelings of insecurity, rejection and fear. The difficult task of implanting new routines has already been described in a previous study, it being recognized that policies which aim to change the behavior of the practitioners in order to improve safety are less likely to be successful if they do not take the pre-existing practices into account (5) .  (24) . Another study notes that the team must be involved for there to be understanding, valuing and awareness of the relevance of patient identification, and that the participation of the nursing staff is of fundamental importance in defining the strategies which will be effective in implanting and improving the practices. In order to guarantee patient safety, it is necessary to raise the awareness of all the professionals that the provision of appropriate care, causing no harm, is a responsibility not only of nursing, but of all the teams which interact with the patient (25) .
It is considered that one limitation of this study is the fact that it was undertaken at that particular time at the institution, characterized by the implementation of a high number of new routines, and by the turmoil of the process of Hospital Accreditation, which may suggest an increase in the rate of patients identified correctly.
Another consideration to be made is related to this study's objectives, as it proposed to analyze one of the aspects of identifying the patients: the presence of the wristband on the patients' forearms, and the accuracy of the information inserted in these wristbands. The undertaking of studies which seek to investigate the use of the wristband by the professionals of the institution prior to the provision of care is also necessary in order to assess the process of identification as a whole. This practice's implementation was verified by the rates of patients with the wristband and by the rates of correct wristbands in accordance with the institution's SOP. It was ascertained that the use of the two identifiers, the complete name and registration number, is widely spread among the professionals who insert these data in the wristbands. Data were also found which brought results referent to the visual aspects of the wristband, such as its physical integrity, its legibility, and its color.