An Analysis of Reports on Incidents/Accidents Related to the Misidentification of Patients – Relationships among Factors Influencing Patient Misidentification –

DOI Web Site
  • KAMIYA Mikiko
    Ikeda Municipal Hospital, Medical safety and quality management section, Safety measures room Kyoto Tachibana University Nursing Graduate School of Nursing Department
  • UEDA Mayumi
    Ikeda Municipal Hospital, Medical safety and quality management section, Safety measures room

Bibliographic Information

Other Title
  • 患者誤認に関するインシデント・アクシデントレポートの分析 −誤認の発生要因の関係−
  • 患者誤認に関するインシデント・アクシデントレポートの分析 : 誤認の発生要因の関係
  • カンジャ ゴニン ニ カンスル インシデント ・ アクシデントレポート ノ ブンセキ : ゴニン ノ ハッセイ ヨウイン ノ カンケイ

Search this article

Description

Objective: The present study analyzed reports on the incidents and accidents that had occurred in a hospital to examine the status of the misidentification of patients and its characteristics, and discuss effective measures for its early detection and prevention. Subjects and Methods: Of the incident/accident reports on the misidentification of patients submitted during a period of one year, 141 were selected, and relationships among the following factors influencing the misidentification were analyzed: "types of job related to the causes", "types of misidentification", "details of misidentification", "event levels of incidents/accidents", "details of misidentifications", "primary causes of misidentifications", "influences of misidentifications on patients", "persons who identified the misidentifications of patients", and "types of job reported". Results: Whereas patient misidentification due to "errors and the violation of rules while confirming names and other information" was primarily identified by health care professionals, that due to "mix-ups while performing multiple tasks" was often identified by patients and their families, and the difference was significant (p<0.05). From the viewpoint of influences on patients, most patient misidentifications due to "errors and the violation of rules while confirming names and other information" were determined as Level-0 events, for which specific measures had not been implemented, and the majority of patient misidentifications due to "mix-ups while performing multiple tasks" were determined as Level-1 or higher events (p<0.05). In a comparison of nurses and other health care professionals, the frequency of nurses’ misidentifications of patients identified by health care professionals was significantly higher than that identified by patients and their families (p<0.05). Conclusions: It is essential to implement education and establish systems designed to help avoid performing multiple tasks at the same time. The results also suggest that it is necessary to encourage health care professionals to place an emphasis on confirmation involving patients, and continue to promote these activities of the hospital.

Journal

Keywords

Details 詳細情報について

Report a problem

Back to top