Department of Medicine, Clinical Laboratories Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
Am J Clin Pathol. 2010 Jun;133(6):870-7. doi: 10.1309/AJCPC95YYMSLLRCX.
Ensuring accurate patient identification is central to preventing medical errors, but it can be challenging. We implemented a bar code-based positive patient identification system for use in inpatient phlebotomy. A before-after design was used to evaluate the impact of the identification system on the frequency of mislabeled and unlabeled samples reported in our laboratory. Labeling errors fell from 5.45 in 10,000 before implementation to 3.2 in 10,000 afterward (P = .0013). An estimated 108 mislabeling events were prevented by the identification system in 1 year. Furthermore, a workflow step requiring manual preprinting of labels, which was accompanied by potential labeling errors in about one quarter of blood "draws," was removed as a result of the new system. After implementation, a higher percentage of patients reported having their wristband checked before phlebotomy. Bar code technology significantly reduced the rate of specimen identification errors.
确保准确的患者身份识别是预防医疗差错的核心,但这可能具有挑战性。我们为住院患者采血实施了基于条码的阳性患者身份识别系统。采用前后设计来评估识别系统对实验室报告的错误标签和未标签样本频率的影响。标签错误率从实施前的每 10000 个样本 5.45 个降至实施后的每 10000 个样本 3.2 个(P =.0013)。该识别系统在 1 年内防止了约 108 次错误标签事件。此外,由于新系统,一个需要手动预打印标签的工作流程步骤被移除,该步骤可能导致约四分之一的血液“采集”存在潜在的标签错误。实施后,接受采血前检查腕带的患者比例更高。条码技术显著降低了标本识别错误率。