Baystate Medical Center, Springfield, MA, USA.
Ann Emerg Med. 2010 Jun;55(6):503-9. doi: 10.1016/j.annemergmed.2009.11.017. Epub 2009 Dec 23.
We evaluate the frequency and accuracy of health care workers verifying patient identity before performing common tasks.
The study included prospective, simulated patient scenarios with an eye-tracking device that showed where the health care workers looked. Simulations involved nurses administering an intravenous medication, technicians labeling a blood specimen, and clerks applying an identity band. Participants were asked to perform their assigned task on 3 simulated patients, and the third patient had a different date of birth and medical record number than the identity information on the artifact label specific to the health care workers' task. Health care workers were unaware that the focus of the study was patient identity.
Sixty-one emergency health care workers participated--28 nurses, 16 technicians, and 17 emergency service associates--in 183 patient scenarios. Sixty-one percent of health care workers (37/61) caught the identity error (61% nurses, 94% technicians, 29% emergency service associates). Thirty-nine percent of health care workers (24/61) performed their assigned task on the wrong patient (39% nurses, 6% technicians, 71% emergency service associates). Eye-tracking data were available for 73% of the patient scenarios (133/183). Seventy-four percent of health care workers (74/100) failed to match the patient to the identity band (87% nurses, 49% technicians). Twenty-seven percent of health care workers (36/133) failed to match the artifact to the patient or the identity band before performing their task (33% nurses, 9% technicians, 33% emergency service associates). Fifteen percent (5/33) of health care workers who completed the steps to verify patient identity on the patient with the identification error still failed to recognize the error.
Wide variation exists among health care workers verifying patient identity before performing everyday tasks. Education, process changes, and technology are needed to improve the frequency and accuracy of patient identification.
我们评估医护人员在执行常见任务前核实患者身份的频率和准确性。
该研究包括前瞻性模拟患者场景，使用眼动追踪设备显示医护人员的视线位置。模拟场景包括护士进行静脉注射、技师标记血样、职员佩戴身份腕带。参与者被要求在 3 名模拟患者身上执行其指定任务，而第 3 名患者的出生日期和医疗记录号码与特定于医护人员任务的人工制品标签上的身份信息不同。医护人员不知道研究的重点是患者身份。
共有 61 名急诊医护人员参与了 183 个患者场景，包括 28 名护士、16 名技师和 17 名急诊服务助理。61%的医护人员（37/61）发现了身份错误（61%的护士、94%的技师、29%的急诊服务助理）。39%的医护人员（24/61）在错误的患者身上执行了指定任务（39%的护士、6%的技师、71%的急诊服务助理）。有 73%的患者场景（133/183）可获得眼动追踪数据。74%的医护人员（74/100）未能将患者与身份腕带匹配（87%的护士、49%的技师）。27%的医护人员（133 名中的 36 名）在执行任务前未能将人工制品与患者或身份腕带匹配（33%的护士、9%的技师、33%的急诊服务助理）。在发现身份错误的患者身上完成验证患者身份步骤的 15%（5/33）医护人员仍未能识别出错误。
医护人员在执行日常任务前核实患者身份的频率和准确性存在很大差异。需要教育、流程改变和技术来提高患者身份识别的频率和准确性。
