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护理过程中的患者身份识别错误。

Patient misidentification in nursing care.

作者信息

Bártlová Sylva, Hajduchová Hana, Brabcová Iva, Tóthová Valérie

机构信息

University of South Bohemia in České Budějovice, Faculty of Health and Social Studies, Department of Nursing and Midwifery, České Budějovice, Czech Republic.

出版信息

Neuro Endocrinol Lett. 2015;36 Suppl 2:17-22.

Abstract

GOAL

The goal of the study was to assess the opinions of nurses regarding patient safety associated with patient misidentification. The investigation was focused on actual patient misidentification as well as loss of patient materials (e.g., blood samples, X-rays, etc.). These are problems often associated with patient identification methods and/or confusing patients with the same surname assigned to the same ward. The risks of misidentification incidents pose a considerable threat to patient health especially when the confusion extends to the operating room. Our objective was to identify the potential causes of patient misidentification and offers solutions to correct the issue.

METHODS

A survey as part of a sociological investigation was carried out through the use of questionnaires. The selected sample included, in accordance with the needs of the project and methodology of the Institute for Health Care Information and Statistics of the Czech Republic, registered nurses working shifts on inpatient wards. The study took place across the Czech Republic between Sept. 15 and 30, 2013. The sample consisted of 772 registered nurses.

RESULTS

The potential for patient misidentification (PM) was described as negligible by 73.8% of respondents. Only 9.1% of nurses admitted problems associated with patient misidentification. Respondents reported that the greatest potential for patient misidentification was associated with patients having the same surname staying on the same ward. An absolute majority of nurses responded that patient identification wristbands were the most frequently used method to prevent PM. Over 90% (90.6%) of nurses reported that patient ID wristbands were used for all patients. Almost 80% (77.4%) reported the use of positive verbal identification in addition to ID wrist bands. Respondents reported (76.2%) that the most frequently used method to avoid PM in the operating room involved a review of patient documentation. Almost the same number of repondents (74.1%) reported the use of verbal confirmation as a method to avoid PM. Another mechanism included verification of the surgical procedure. ID wristbands and completion of an 'identification protocol' rank among other options mentioned most frequently by respondents.

CONCLUSION

The study shows that registered nurses regard patient misidentification as a very rare and unlikely event. Nonetheless, statistics suggest otherwise and education, changes in protocols, and new technologies are needed to improve the precision of patient identification.

摘要

目标

本研究的目的是评估护士对与患者身份识别错误相关的患者安全问题的看法。调查重点关注实际的患者身份识别错误以及患者资料丢失(如血样、X光片等)。这些问题通常与患者身份识别方法和/或将姓氏相同的患者安排在同一病房所造成的混淆有关。身份识别错误事件的风险对患者健康构成了相当大的威胁,尤其是当混淆延伸到手术室时。我们的目标是找出患者身份识别错误的潜在原因并提供解决该问题的方案。

方法

作为一项社会学调查的一部分,通过问卷调查展开了研究。根据项目需求和捷克共和国医疗保健信息与统计局的方法,选定的样本包括在住院病房轮班工作的注册护士。该研究于2013年9月15日至30日在捷克共和国全境进行。样本由772名注册护士组成。

结果

73.8%的受访者称患者身份识别错误(PM)的可能性可忽略不计。只有9.1%的护士承认存在与患者身份识别错误相关的问题。受访者报告称,患者身份识别错误的最大可能性与姓氏相同的患者住在同一病房有关。绝大多数护士回应称,患者身份识别腕带是预防身份识别错误最常用的方法。超过90%(90.6%)的护士报告称对所有患者都使用了患者身份识别腕带。近80%(77.4%)的护士报告除了身份识别腕带外还使用了积极的口头身份确认。受访者报告(76.2%)称,在手术室避免身份识别错误最常用的方法是查看患者病历。几乎相同数量的受访者(74.1%)报告使用口头确认作为避免身份识别错误的一种方法。另一种机制包括核实手术程序。身份识别腕带和完成“身份识别协议”是受访者提及最频繁的其他选项。

结论

研究表明,注册护士认为患者身份识别错误是非常罕见且不太可能发生的事件。尽管如此,统计数据却并非如此,需要通过教育、协议变更和新技术来提高患者身份识别的准确性。

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