Errores en la identificación del paciente y en muestras biológicas en el proceso analítico¿es posible la mejora de la seguridad de los pacientes?
- M.A. Cuadrado-Cenzual 1
- M. García Briñón 2
- Y. de Gracia Hills 1
- M. González Estecha 1
- Collado Yurrita 3
- J.A. de Pedro Moro 4
- C. Fernández Pérez 5
- M. Arroyo Fernández 1
- 1 Gestión Clínica, Análisis Clínicos, Hospital Clínico San Carlos, Madrid, España
- 2 Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, España
- 3 Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
- 4 Facultad de Medicina, Universidad de Salamanca, Salamanca, España
- 5 Medicina Preventiva, Hospital Clínico San Carlos, Madrid, España
ISSN: 1134-282X
Year of publication: 2015
Volume: 30
Issue: 6
Pages: 310-318
Type: Article
More publications in: Revista de calidad asistencial
Abstract
Background Patient identification errors and biological samples are one of the problems with the highest risk factor in causing an adverse event in the patient. Objective To detect and analyse the causes of patient identification errors in analytical requests (PIEAR) from emergency departments, and to develop improvement strategies. Material and methods A process and protocol was designed, to be followed by all professionals involved in the requesting and performing of laboratory tests. Evaluation and monitoring indicators of PIEAR were determined, before and after the implementation of these improvement measures (years 2010-2014). Results A total of 316 PIEAR were detected in a total of 483,254 emergency service requests during the study period, representing a mean of 6.80/10,000 requests. Patient identification failure was the most frequent in all the 6-monthly periods assessed, with a significant difference (P < .0001). Conclusions The improvement strategies applied showed to be effective in detecting PIEAR, as well as the prevention of such errors. However, we must continue working with this strategy, promoting a culture of safety for all the professionals involved, and trying to achieve the goal that 100% of the analytical and samples are properly identified.