Identificação do paciente

WHO Collaborating Centre for Patient Safety Solutions
Aide Memoire
Patient Identification
The Joint Commission
Joint Commission International
Patient Safety Solutions
WHO Collaborating
Centre
| volume 1, solution
2 | May 2007for Patient Safety Solutions
▶ Statement of Problem and ImPact:
Throughout the health-care industry, the failure to correctly
identify patients continues to result in medication errors, transfusion errors, testing errors, wrong person procedures, and the
discharge of infants to the wrong families. Between November
2003 and July 2005, the United Kingdom National Patient
Safety Agency reported 236 incidents and near misses related
to missing wristbands or wristbands with incorrect information (1). Patient misidentification was cited in more than 100
individual root cause analyses by the United States Department
of Veterans Affairs (VA) National Center for Patient Safety from
January 2000 to March 2003 (2). Fortunately, available interventions and strategies can significantly reduce the risk of
patient misidentification.
There are newer technologies which can improve patient identification, for example, bar coding. Some of these have proved
to be cost-effective (6-11).
Organização Mundial da SaúdeRegardless of the technology or approach used for accuAide Memoire
▶ aSSocIated ISSueS:
rately identifying patients, careful planning for the processes
of care will ensure proper patient identification prior to any
medical intervention and provide safer care with significantly
fewer errors.
▶ SuggeSted actIonS:
The following strategies should be considered by WHO
Member States.
1. Ensure that health-care organizations have systems in
place that:
The major areas where patient misidentification can occur
include drug administration, phlebotomy, blood transfusions,
and surgical interventions. The trend towards limiting working
hours for clinical team members leads to an increased number
of team members caring for each patient, thereby increasing
the likelihood of hand-over and other communication problems (3). Because patient misidentification is identified as a
root cause of many errors, the Joint Commission, in the United
States of America, listed improving patient identification accuracy as the first of its National Patient Safety Goals introduced
in 2003, and this continues to be an accreditation requirement
(4). While in some countries wristbands are traditionally used
for identifying hospitalized patients, missing bands or incorrect information limit the efficacy of this system. Colour coding of wristbands facilitates rapid visual recognition of specific
issues, but the lack of a standardized coding system has lead
to errors by staff who provide care at multiple facilities (5).
a. Emphasize the primary responsibility of health-care
workers to check the identity of patients and match
the correct patients with the correct care (e.g. laboratory results, specimens, procedures) before that care
is administered.
Identificação do paciente
b. Encourage the use of at least two identifiers (e.g. name
and date of birth) to verify a patient’s identity upon admission or transfer to another hospital or other care setting and prior to the administration of care. Neither of
these identifiers should be the patient’s room number.
c. Standardize the approaches to patient identification
among different facilities within a health-care system.
For example, use of white ID bands on which a standardized pattern or marker and specific information (e.g.
name and date of birth) could be written, or
implementation of biometric technologies.
Soluções de segurança do paciente
volume 1, solução 2, maio de 2007
WHO Collaborating Centre for Patient Safety Solutions
Aide Memoire
Patient Identification
© Organização Mundial da Saúde, 2007
Todos os direitos reservados. As publicações da Organização Mundial da Saúde podem ser obtidas na
WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791
Patient Safety Solutions
3264; fax: +41 22 791 4857; e-mail: [email protected]).
Pedidos de autorização para reproduzir ou traduzir
| volume 1, solution 2 | May 2007
as publicações da OMS — seja para a venda ou para a distribuição não comercial — devem ser dirigidas à
WHO Press no endereço acima (fax:
+41 22 791 4806; e-mail: [email protected]).
▶ Statement of Problem and ImPact:
Throughout the health-care industry, the failure to correctly
There are newer technologies which can improve patient idenAs designações utilizadas e a apresentação
do material
nesta publicação
nãoforimplicam
a expressão de qualidentify patients continues
to result in medication
errors, trans- tification,
example, bar coding. Some of these have proved
fusion
errors,
testing
errors,
wrong
person
procedures,
and
the
to
be
cost-effective
(6-11).
quer opinião da Organização Mundial da Saúde sobre o status jurídico de qualquer país, território, cidade ou
discharge of infants to the wrong families. Between November
Regardless of the technology or approach used for accuárea, sobre as suas autoridades ou sobre
a July
delimitação
suasNational
fronteiras
ou limites. As linhas pontilhadas em
2003 and
2005, the Uniteddas
Kingdom
Patient
rately identifying patients, careful planning for the processes
Safety Agency reported 236 incidents and near misses related
of care will
ensure
proper patient
identification prior to any
mapas representam as fronteiras aproximadas
sobre
as
quais
ainda
não
existe
um
acordo
pleno.
to missing wristbands or wristbands with incorrect information (1). Patient misidentification was cited in more than 100
medical intervention and provide safer care with significantly
fewer errors.
A menção de empresas específicas
ourootdos
produtos
deStates
certos
fabricantes
não implica que estes sejam
individual
cause analyses
by the United
Department
of Veterans Affairs (VA) National Center for Patient Safety from
endossados nem recomendados pela
Organização Mundial da Saúde em
de outros produtos ou
▶ detrimento
SuggeSted actIonS:
January 2000 to March 2003 (2). Fortunately, available inThe
following
strategies
should
be e
considered
by WHO
terventions
strategies can
significantly
reduce the risk of Exceto no caso de
empresas de natureza semelhante que
nãoandtenham
sido
mencionados.
erros
omissões,
os
Member States.
patient misidentification.
nomes de produtos de marca registrada são diferenciados pelo uso de iniciais
maiúsculas.
1. Ensure that health-care organizations have systems in
▶ aSSocIated ISSueS:
place that:
A Organização Mundial da Saúde
tomou todas as precauções necessárias
paratheverificar
as informações
a. Emphasize
primary responsibility
of health-care
The major areas where patient misidentification can occur
workers
to
check
the
identity
of patients
include
drug
administration,
phlebotomy,
blood
transfusions,
contidas nesta publicação. Entretanto, o material publicado está sendo distribuído sem nenhum
tipoanddematch
gathe correct patients with the correct care (e.g. laboraand surgical interventions. The trend towards limiting working
rantia, seja esta explícita ou implícita.
A
responsabilidade
pela
interpretação
e
uso
deste
material
recai
sobre
tory results, specimens, procedures) before that care
hours for clinical team members leads to an increased number
is administered.
team members
for each patient,
thereby increasingcircunstância,
o leitor. A Organização Mundial daof Saúde
nãocaring
poderá,
em nenhuma
ser responsabilizada por
the likelihood of hand-over and other communication probb. Encourage the use of at least two identifiers (e.g. name
danos oriundos de seu uso.
lems (3). Because patient misidentification is identified as a
and date of birth) to verify a patient’s identity upon adroot cause of many errors, the Joint Commission, in the United
mission or transfer to another hospital or other care set-
America,coletivo
listed improving
identification
accuting
and prior tofor
the administration
of care. Neither
of
Esta publicação contém o pontoStates
deofvista
dopatient
WHO
Collaborating
Centre
Patient Safety
Soluracy as the first of its National Patient Safety Goals introduced
these identifiers should be the patient’s room number.
tions e de seu International Steering
Committee
representa
necessariamente as decisões ou políticas
in 2003,
and this continueseto não
be an accreditation
requirement
c. Standardize the approaches to patient identification
(4).
While
in
some
countries
wristbands
are
traditionally
used
expressas da Organização Mundial da Saúde.
among different facilities within a health-care system.
Proqualis/Instituto de
for identifying hospitalized patients, missing bands or incorFor example, use of white ID bands on which a standrect information limit the efficacy of this system. Colour codardized pattern or marker and specific information (e.g.
ing of wristbands facilitates rapid visual recognition of specific
name and date of birth) could be written, or
issues, but the lack of a standardized coding system has lead
implementation of biometric technologies.
to errors
by staff whoeprovide
care at multiple
facilities
(5).
Comunicação
Científica
Tecnológica
em
Saúde/Fiocruz,
2014
Coordenação Geral: Claudia Maria Travassos
Coordenação Executiva: Victor Grabois
Revisão técnica: Camila Lajolo
Revisão gramatical/Copydesk: Priscilla Mouta Marques
Edição Executiva: Alessandra dos Santos e Miguel Papi
Tradução: Diego Alfaro
Creative Commons Atribuição-NãoComercial 3.0 Não Adaptada
WHO Collaborating Centre for Patient Safety Solutions
Aide Memoire
Patient Identification
APRESENTAÇÃO DO PROBLEMA E SEU IMPACTO:
seiras ou a inclusão de informações incorretas limiEm toda a indústria da saúde, a dificuldade em
tam a eficácia desse sistema. O uso de pulseiras de
identificar corretamente os pacientes continua a
identificação com códigos de cores facilita o rápido
resultar em erros de medicação, em erros de transPatient complemenSafety Solutions
reconhecimento visual de questões específicas, mas
fusão, em erros relacionados a exames
| volume 1, solution 2 | May 2007
a ausência de um sistema de codificação padronizatares, na realização de procedimentos na pessoa erdo provoca erros por parte de profissionais de saúde
rada e na alta hospitalar de bebês para as famílias
▶ Statement of Problem and ImPact:
que trabalham em várias instituições diferentes (5).
erradas. Entre novembro de 2003 e julho de 2005, a
Throughout the health-care industry, the failure to correctly There are newer technologies which can improve patient idenNational Patient Safety Agency do Reino
Unido
noidentify patients
continues
to result in medication errors, trans- tification, for example, bar coding. Some of these have proved
Existem
fusion errors, testing errors, wrong person procedures,
andnovas
the to betecnologias
cost-effective (6-11).capazes de melhorar a
tificou 236 incidentes e near misses
relacionados
à
discharge of infants to the wrong families. Between November
identificação
de
pacientes;
exemplo,
o uso
deaccucóRegardless of the por
technology
or approach
used for
2003 and
United Kingdom National Patient
ausência de pulseiras de identificação
ouJulyao2005,
usothede
rately identifying patients, careful planning for the processes
Safety Agency reported 236 incidents digos
and near misses
related
de barras.
Foi demonstrado que algumas desof care will ensure proper patient identification prior to any
pulseiras com informações incorretas
(1).wristbands
A identito missing
or wristbands with incorrect informaintervention and provide
safer care with
sas tecnologias medical
são vantajosas
em termos
designificantly
custotion (1). Patient misidentification was cited in more than 100
ficação incorreta de pacientes foi citada
em mais de
fewer errors.
individual root cause analyses by the United
States
Department
-efetividade (6-11).
100 análises de causa-raiz individuais
pelo
United
of Veterans
Affairs (VA)
National Center for Patient Safety from
▶ SuggeSted actIonS:
January 2000 to March 2003 (2). Fortunately, available inStates Department of Veterans Affairs
(VA)
National
Independentemente
tecnologia
da abordaThe
followingda
strategies
should be ou
considered
by WHO
terventions and strategies can significantly reduce the risk of
Member States.
Center for Patient Safety de janeiropatient
de misidentification.
2000 a margem usada para identificar pacientes com precisão,
1. Ensure that health-care organizations have systems in
ço de 2003 (2). Felizmente, existem intervenções e
o planejamento cuidadoso
dos processos de cuidaplace that:
▶ aSSocIated ISSueS:
estratégias capazes de reduzir significativamente
o misidentification
do irá assegurar
a a.identificação
correta
de pacientes
Emphasize the primary
responsibility
of health-care
The major areas where patient
can occur
workers to check the identity of patients and match
include
drug
administration,
phlebotomy,
blood
transfusions,
risco de identificação incorreta de pacientes.
antes da realização de
qualquer
intervenção
médica,
the correct patients with the correct care (e.g. laboraand surgical interventions. The trend towards limiting working
tory mais
results, specimens,
before
that care
um cuidado
seguroprocedures)
com um
número
hours for clinical team members leadslevando
to an increasedanumber
is administered.
of team members caring for each patient, thereby increasing
de erros significativamente mais baixo.
the likelihood of hand-over and other communication prob-
QUESTÕES RELACIONADAS:
lems (3). Because patient misidentification is identified as a
root cause of many errors, the Joint Commission, in the United
States of America, listed improving patient identification accuracy as the first of its National Patient Safety Goals introduced
in 2003, and this continues to be an accreditation requirement
(4). While in some countries wristbands are traditionally used
for identifying hospitalized patients, missing bands or incorrect information limit the efficacy of this system. Colour coding of wristbands facilitates rapid visual recognition of specific
issues, but the lack of a standardized coding system has lead
to errors by staff who provide care at multiple
►► facilities (5).
As principais áreas que podem ser afetadas pela
identificação incorreta de pacientes são a administração de medicamentos, as punções venosas, as
transfusões de sangue e as intervenções cirúrgicas.
A tendência a limitar o número de horas de trabalho dos profissionais de equipes clínicas faz com que
um maior número de profissionais cuide de cada paciente, aumentando, assim, a probabilidade de que
ocorram problemas nas passagens de caso ou outros
problemas de comunicação (3). Como a identificação incorreta de pacientes é a causa-raiz de muitos
erros, a Joint Commission dos Estados Unidos citou a
maior precisão na identificação de pacientes como o
primeiro de seus Objetivos Nacionais de Segurança
do Paciente, introduzidos em 2003, e esse continua
a ser um requisito para a acreditação (4). Em alguns
países é comum o uso de pulseiras de identificação
de pacientes internados; no entanto, a perda de pul-
b. Encourage the use of at least two identifiers (e.g. name
and date of birth) to verify a patient’s identity upon admission or transfer to another hospital or other care setting and prior to the administration of care. Neither of
these identifiers should be the patient’s room number.
AÇÕES SUGERIDAS:
c. Standardize the approaches to patient identification
among different facilities within a health-care system.
For example, use of white ID bands on which a standardized pattern or marker and specific information (e.g.
name and date of birth) could be written, or
implementation of biometric technologies.
Os Estados-Membros da OMS devem considerar
as seguintes estratégias:
Assegurar que as organizações de saúde possuam sistemas que:
►►
►►
Enfatizem a responsabilidade primária dos
profissionais de saúde na tarefa de verificar a
identidade dos pacientes e de fazer a correspondência entre o paciente correto e o cuidado correto (p.ex., resultados laboratoriais,
amostras, procedimentos) antes da administração do cuidado.
Promovam o uso de, no mínimo, dois identificadores (p.ex., nome e data de nascimento)
para verificar a identidade de um paciente
no momento da internação ou da transfe-
WHO Collaborating Centre for Patient Safety Solutions
rência para outro hospital ou outro ambiente
de cuidado e antes da administração do cuidado. O número do quarto do paciente não
deve ser usado como um identificador.
►►
►►
►►
►►
►►
►►
►►
►►
Aide Memoire
Patient
Identification
Educar
os pacientes sobre a importância e a re►►
levância da correta identificação de uma forma
positiva, que também respeite suas preocupações ligadas à privacidade.
Padronizem as abordagens para a identifiPatient Safety Solutions
cação de pacientes entre diferentes
unidades
| volume 1, solution
2 | May 2007 QUESTÕES FUTURAS:
do sistema de saúde. Por exemplo, o uso de
pulseiras de identificação brancas
nas of
quais
▶ Statement
Problem and
►► ImPact:
Considerar a implementação de sistemas autopossam ser escritos um marcador
Throughout thepadronihealth-care industry, the failure to correctly There are newer technologies which can improve patient idenmatizados (p.ex., prescrições eletrônicas, códiidentify patients continues to result in medication errors, trans- tification, for example, bar coding. Some of these have proved
zado e informações específicas
(p.ex.,
nome
fusion errors, testing errors, wrong person procedures,
and the
gos de
barras,
identificação
por radiofrequênto be cost-effective
(6-11).
of infants to the wrong families. Between November
e data de nascimento), ou adischarge
implementação
Regardless
of the
technologyo or
approach usedde
forerros
accucia, biometria)
para
reduzir
potencial
2003 and July 2005, the United Kingdom National
Patient
rately identifying patients, careful planning for the processes
de tecnologias biométricas.Safety Agency reported 236 incidents and nearde
misses
related
identificação, quando viável.
to missing wristbands or wristbands with incorrect information (1). Patient misidentification was cited in more than 100
individual root cause analyses by the United States Department
of Veterans Affairs (VA) National Center for Patient Safety from
January 2000 to March 2003 (2). Fortunately, available interventions and strategies can significantly reduce the risk of
patient misidentification.
Utilizem protocolos claros para identificar
pacientes sem identificação e para distinguir a identidade de pacientes com o mesmo
nome. É preciso desenvolver e utilizar abordagens não verbais para identificar pacientes
comatosos ou confusos. ▶ aSSocIated ISSueS:
of care will ensure proper patient identification prior to any
medical intervention and provide safer care with significantly
fewer errors.
SuggeSted actIonS:
FORÇA DAS▶EVIDÊNCIAS:
The following strategies should be considered by WHO
Member States.
Consensos1.e relatórios
de especialistas indicam
Ensure that health-care organizations have systems in
place
that:
reduções significativas na ocorrência de erros
a. Emphasize the primary responsibility of health-care
The major areas where patient misidentification
occur
emcan
unidades
específicas
após a implementação
workers to check the identity of patients and match
include drug administration, phlebotomy, blood transfusions,
Estimulem os pacientes a participar
de
todas
the
correct
patients
with the correct care
laborade
novos
processos
de
identificação
do (e.g.
pacienand surgical interventions. The trend towards limiting working
tory results, specimens, procedures) before that care
hours for clinical team members leads to an increased number
as etapas do processo.
te.
is administered.
of team members caring for each patient, thereby increasing
the
likelihood
of
hand-over
and
other
communication
probb.
Encourage the use of at least two identifiers (e.g. name
Estimulem a rotulagem de recipientes usalems (3). Because patient misidentification is identified as a
and date of birth) to verify a patient’s identity upon addos para armazenar sanguerootecause
outras
amosof many errors,
the Joint Commission, in the United
mission or transfer to another hospital or other care setAPLICABILIDADE:
States of America, listed improving patient
identification accuting and prior to the administration of care. Neither of
tras na presença do paciente.
►►
racy as the first of its National Patient Safety Goals introduced
in 2003, and this continues to be an accreditation requirement
►► traditionally used
(4). While in some countries wristbands are
for identifying hospitalized patients, missing bands or incorrect information limit the efficacy of this system. Colour coding of wristbands facilitates rapid visual recognition of specific
issues, but the lack of a standardized coding system has lead
to errors by staff who provide care at multiple facilities (5).
Utilizem protocolos claros para manter a
identificação de amostras ao longo de todos
os processos pré-analíticos, analíticos e pós-analíticos.
Utilizem protocolos claros para questionar
resultados laboratoriais ou laudos de outros
exames quando estes não forem consistentes
com a história clínica do paciente.
Realizem verificações repetidas e revisões
para evitar a multiplicação automatizada de
erros na introdução de dados num computador.
Incluir, nos programas de desenvolvimento
profissional continuado dos profissionais de
saúde, o treinamento em procedimentos de verificação da identidade do paciente.
these identifiers should be the patient’s room number.
Todos os ambientes de prestação do cuidado de
saúde.
c. Standardize the approaches to patient identification
among different facilities within a health-care system.
For example, use of white ID bands on which a standardized pattern or marker and specific information (e.g.
name and date of birth) could be written, or
implementation of biometric technologies.
OPORTUNIDADES DE ENVOLVIMENTO
DOS PACIENTES E DAS FAMÍLIAS:
►►
►►
►►
Educar os pacientes sobre os riscos relacionados à identificação incorreta.
Pedir aos pacientes ou aos seus familiares que
verifiquem se as informações de identificação
estão corretas.
Pedir aos pacientes que se identifiquem antes
de receber qualquer medicamento e antes de
ser submetidos a qualquer intervenção diagnóstica ou terapêutica.
WHO Collaborating Centre for Patient Safety Solutions
►►
Estimular os pacientes e suas famílias ou representantes a participar ativamente da identificação, a expressar suas preocupações ligadas à segurança e à possível ocorrência de
erros e a fazer perguntas sobre a adequação
Patient Safety Solutions
do cuidado.
PatientAltoIdentification
risco de identificação incorreta do pa►►
ciente devido à estrutura do nome, à existência de nomes muito parecidos e à imprecisão
na data de nascimento de pacientes idosos.
►►
| volume 1, solution 2 | May 2007
►►
POSSÍVEIS BARREIRAS:
►►
►►
►►
►►
►►
►►
►►
►►
►►
►►
Aide Memoire
Pacientes que utilizam cartões de saúde de
outras pessoas para obter acesso aos serviços.
Roupas que escondem a identidade.
▶ Statement of Problem and ImPact:
►►
Falta deThere
familiaridade
com os nomes locais
are newer technologies which can improve patient identification,
for example,
bar coding.
Some vez
of thesemaior
have proved
por parte
de um
número
cada
de
to be cost-effective (6-11).
profissionais de saúde estrangeiros.
Throughout the health-care industry, the failure to correctly
identify patients continues to result in medication errors, transfusion errors, testing errors, wrong person procedures, and the
discharge of infants to the wrong families. Between November
2003 and July 2005, the United Kingdom National Patient
►
Safety Agency reported 236 incidents and►near
misses related
to missing wristbands or wristbands with incorrect information (1). Patient misidentification was cited in more than 100
individual root cause analyses by the United States Department
of Veterans Affairs (VA) National Center for Patient Safety from
January 2000 to March 2003 (2). Fortunately, available interventions and strategies can significantly reduce the risk of
patient misidentification.
Dificuldade em atingir mudanças no comportamento individual que aumentem a adesão às
recomendações, evitando o uso de atalhos e outras formas de contornar os protocolos.
Regardless of the technology or approach used for accu-
rately identifying patients, careful planning for the processes
Insuficiência
de estudos, dados e razões econôof care will ensure proper patient identification prior to any
interventionde
andcusto-benefício
provide safer care with significantly
micas sobremedical
a análise
ou de
fewer errors.
retorno sobre o investimento para a implemenSuggeSted actIonS:
tação destas▶recomendações.
Variabilidade nos processos de diferentes organizações de uma mesma área geográfica.
The following strategies should be considered by WHO
Member States.
Variabilidade nos processos de diferentes orga1. Ensure that health-care organizations have systems in
place that:
RISCO DE CONSEQUÊNCIAS
nizações regionais que empregam
os mesmos
▶ aSSocIated
ISSueS:
a. Emphasize the primary responsibility of health-care
major areas where patient misidentification can occur
profissionais (p.ex., pulseiras The
com
códigos de
to check the identity of patients and match
include drug administration, phlebotomy, blood transfusions,
INESPERADAS: workers
the correct patients with the correct care (e.g. laboracores com diferentes significados
em interventions.
diferentes
and surgical
The trend towards limiting working
tory results, specimens, procedures) before that care
hours for clinical team members leads to an increased number
organizações).
is administered.
of team members caring for each patient,
thereby increasing
►► Descuido em relação à avaliação de procesthe likelihood of hand-over and other communication probb. Encourage the use of at least two identifiers (e.g. name
Custos associados a possíveis soluções
técnicas.
básicos
de cuidado
à preocupação
lems (3). Because
patient misidentification issos
identified
as a
and date of birth)devido
to verify a patient’s
identity upon adroot cause of many errors, the Joint Commission, in the United
mission or transfer to another hospital or other care setcom
instrumentos
ou
soluções
técnicas
e nãoIntegração da tecnologia dentro
deof America,
uma organiStates
listed improving patient identification accuting and prior to the administration of care. Neither of
racy as the first of its National Patient Safety Goals
introduced
-técnicas.
these identifiers should be the patient’s room number.
zação e entre distintas organizações.
in 2003, and this continues to be an accreditation requirement
(4). While in some countries wristbands are
►► traditionally used
for identifying hospitalized patients, missing bands or incorrect information limit the efficacy of this system. Colour coding of wristbands facilitates rapid visual recognition of specific
issues, but the lack of a standardized coding system has lead
to errors by staff who provide care at multiple facilities (5).
Soluções tecnológicas que não consideram a realidade dos ambientes de cuidado.
►►
Aumento da carga de trabalho dos profissionais
e maior tempo gasto com atividades não relacionadas ao cuidado de saúde.
►►
Erros de digitação e inclusão de informações
incorretas ao registrar pacientes em sistemas
computadorizados.
►►
Questões culturais, dentre elas:
►►
►►
Estigma associado ao uso de uma pulseira
de identificação.
c. Standardize the approaches to patient identification
Dependência deamong
soluções
técnicas
adaptar
different facilities
within a sem
health-care
system.
For example, use of white ID bands on which a standos processos deardized
trabalho
relacionados
aos
nopattern or marker and specific information (e.g.
and date of birth) could be written, or
vos sistemas de name
apoio.
Percepção, pelos profissionais de saúde, de que
a relação com o paciente fica comprometida devido à verificação repetida de sua identidade.
implementation of biometric technologies.
Dependência de soluções técnicas imperfeitas
como se fossem perfeitas.
Eliminação de processos humanos de verificação após a implementação de sistemas automatizados.
Rápida replicação de erros em sistemas de computadores em rede, ocultando erros na identificação do paciente.
Possível comprometimento da confidencialidade e da privacidade do paciente pelo uso de
sistemas padronizados de identificação.
WHO Collaborating Centre for Patient Safety Solutions
Aide Memoire
Patient Identification
Patient Safety Solutions
| volume 1, solution 2 | May 2007
EXEMPLO DE
▶ Statement of Problem and ImPact:
Identificação do Paciente
Throughout the health-care industry, the failure to correctly There are newer technologies which can improve patient idenidentify patients continues to result in medication errors, trans- tification, for example, bar coding. Some of these have proved
Enfatizar que os profissionais de saúde têm a responsabilidade primária de verificar a
fusion errors, testing errors, wrong person procedures, and the to be cost-effective (6-11).
identidade do paciente e que os pacientes devem participar ativamente do processo, sendo
discharge of infants to the wrong families. Between November
educados sobre a importância da identificação correta. Regardless of the technology or approach used for accu2003 and July 2005, the United Kingdom National Patient
rately identifying patients, careful planning for the processes
Safety Agency reported 236 incidents and near misses related
of care will ensure proper patient identification prior to any
to missing wristbands or wristbands with incorrect informamedical intervention and provide safer care with significantly
No momento
da internação
e antes
administração
do cuidado, devem ser usados, no
tion (1). Patient
misidentification
wasda
cited
in more than 100
fewer errors.
mínimo,individual
dois identificadores
para
verificar
a identidade
de um paciente. O número do quarto
root cause analyses
by the
United States
Department
do paciente
nãoAffairs
deve(VA)
ser National
usado Center
comofor
um
identificador.
of Veterans
Patient
Safety from
▶ SuggeSted actIonS:
January 2000 to March 2003 (2). Fortunately, available inThe
following strategies should be considered by WHO
terventions and strategies can significantly reduce the risk of
• Padronizar
as abordagens de identificação de pacientesMember
usadas
por diferentes unidades de
States.
patient misidentification.
Política
Internação
Identificadores
de pacientes
um mesmo sistema de saúde. Por exemplo, pelo uso de pulseiras de identificação brancas
1. Ensure that health-care organizations have systems in
nas quais possam ser escritos um marcador padronizado e informações específicas (p.ex.,
place that:
▶ eaSSocIated
ISSueS:
nome
data de nascimento).
a. Emphasize the primary responsibility of health-care
The major um
areasprotocolo
where patient
misidentification
canidentificar
occur
• Desenvolver
organizacional
para
pacientes
sem identificação ou
workers to check the identity of patients and match
drug
administration, phlebotomy, blood transfusions,
cominclude
nomes
iguais.
and surgical interventions. The trend towards limiting working
the correct patients with the correct care (e.g. labora-
• Uso de outras abordagens não verbais, como a biometria, para
comatosos.
torypacientes
results, specimens,
procedures) before that care
hours for clinical team members leads to an increased number
Intervenção
Paciente
Este exemplo não é
is administered.
of team members caring for each patient, thereby increasing
the likelihood of hand-over and other communication probb. Encourage the use of at least two identifiers (e.g. name
lemsque
(3). oBecause
patient de
misidentification
is identified
as a
and
date of birth)
to verify a patient’s
Mesmo
profissional
saúde conheça
o paciente,
deverá
verificar
os detalhes
de suaidentity upon adroot causepara
of many
errors, the
Joint
Commission,
in the United
missioncorreto
or transfer to another hospital or other care setidentificação
garantir
que
o paciente
correto
receba o cuidado
States of America, listed improving patient identification accuting and prior to the administration of care. Neither of
racy as the first of its National Patient Safety Goals introduced
these identifiers should be the patient’s room number.
in 2003, and this continues to be an accreditation requirement
c. Standardize the approaches to patient identification
Envolver
os pacientes
no processo
deareidentificação.
(4). While
in some countries
wristbands
traditionally used
among different facilities within a health-care system.
for identifying hospitalized patients, missing bands or incorFor example, use of white ID bands on which a standrect information limit the efficacy of this system. Colour codardized pattern or marker and specific information (e.g.
ing of wristbands facilitates rapid visual recognition of specific
name and date of birth) could be written, or
necessariamente apropriado
para
todos
os
ambientes
de
saúde.
issues, but the lack of a standardized coding system has lead
implementation of biometric technologies.
to errors by staff who provide care at multiple facilities (5).
WHO Collaborating Centre for Patient Safety Solutions
Aide Memoire
Patient Identification
REFERÊNCIAS:
8. Dighe A et al. Massachusetts General Hospital—bar
coded
patient wristband initiative: a CPM initiative. IHI
1. Wristbands for hospital inpatients improves safety.
National Forum storyboard presentation, dezembro de
National Patient Safety Agency, Safer practice notice 11,
Patient Safety Solutions
2004; Safety Improvement Reports. saferhealthcare, 2005
22 de novembro de 2005. http://www.npsa.nhs.uk/site/
| volume 1, solution 2 | May 2007
(http://www.saferhealthcare.org.uk/IHI/Topics/IntheRemedia/documents/1440_Safer_Patient_Identification_
alWorld/PatientIdentification/ImprovementReports/MasSPN.pdf
▶ Statement of Problem and ImPact:
sachusettsGeneralHospital.htm, acesso em 1 de abril de
Throughout the health-care industry, the failure to correctly There are newer technologies which can improve patient iden2. Mannos D. NCPS patient misidentification
study:
a
2007). errors, trans- tification, for example, bar coding. Some of these have proved
identify patients continues to result in medication
fusion errors,
testing errors,
wrong person procedures, and the to be cost-effective (6-11).
summary of root cause analyses. VA NCPS
Topics
in Padischarge of infants to the wrong families. Between November
9. Wright AA Regardless
et al. Bar
coding
fororpatient
New
of the
technology
approach safety.
used for accutient Safety. Washington, DC, United 2003
States
and Department
July 2005, the United Kingdom National Patient
rately identifying patients, careful planning for the processes
reported 236 incidents England
and near misses
related of Medicine, 2005, 354:329–331.
Journal
of Veterans Affairs, junho-julho de Safety
2003Agency
(http://www.
of care will ensure proper patient identification prior to any
to missing wristbands or wristbands with incorrect informamedical intervention and provide safer care with significantly
va.gov/ncps/TIPS/Docs/TIPS_Jul03.doc,
em 11 was cited10.
tion (1).acesso
Patient misidentification
in more than 100
Emergingfewer
technology:
hospitals turn to RFID.
errors.
individual root cause analyses by the United States Department
de junho de 2006).
of Veterans Affairs (VA) National Center
for Patient Safety from agosto de 2005 http://www.healthleaderHealthLeaders,
January 2000 to March 2003 (2). Fortunately, available in-
▶ SuggeSted actIonS:
smedia.com/print.cfm?content_id=71598&parent=106.
3. Thomas P, Evans C. An identityterventions
crisis?and
Aspects
of significantly
strategies can
reduce the risk of The following strategies should be considered by WHO
Member States.
patient misidentification.
patient misidentification. Clinical Risk, 2004, 10:18–22.
11. Secure identification: the smart card revolution in
aSSocIated
ISSueS:
4. 2006 National Patient Safety ▶Goals.
Oakbrook
1. Ensure that health-care organizations have systems in
place that:
health care. The Silicon Trust, 4 de junho de 2003 (http://
a. Emphasize the primary responsibility of health-care
The major areas where patient misidentification can occur
www.silicon-trust.com/trends/tr_healthcare.html,
acesworkers to check the identity of patients and match
Terrace, IL; Joint Commission, 2006 include
(http://www.jcipadrug administration, phlebotomy, blood transfusions,
the
correct
patients
with
the
correct
care
(e.g.
laboraand surgical interventions. The trend towards
so emlimiting
1 deworking
abril de 2007).
tientsafety.org/show.asp?durki=10293&site=164&retu
tory results, specimens, procedures) before that care
hours for clinical team members leads to an increased number
is administered.
of team members caring for each patient, thereby increasing
rn=10289, acesso em 11 de junho de 2006).
the likelihood of hand-over and other communication probb. Encourage the use of at least two identifiers (e.g. name
lems (3). Because patient misidentification is identified as a
and date of birth) to verify a patient’s identity upon ad5. Use of color-coded patient wristbands creates unroot cause of many errors, the Joint Commission, in the United
mission or transfer to another hospital or other care setnecessary risk. Patient Safety AdvisoryStates
Supplement,
of America, listed Vol.
improving patient identification accuting and prior to the administration of care. Neither of
racy as the first of its National Patient Safety Goals introduced
these identifiers should be the patient’s room number.
2, Sup. 2. Harrisburg, Pennsylvania Patient
Safety
Au1. Greenly
M: Helping Hippocrates: a cross-functionin 2003, and this continues to be an accreditation
requirement
c. Standardize the approaches to patient identification
(4). While in some countries wristbands
traditionally used
thority, 14 de dezembro de 2005 (http://www.psa.state.
alareapproach
to patientamong
identification.
Joint
Commision
different facilities within
a health-care
system.
for identifying hospitalized patients, missing bands or incorFor example, use of white ID bands on which a standpa.us/psa/lib/psa/advisories/v2_s2_sup__advisory_
Journal
on
Quality
and
Patient
Safety,
32:463–469,
agosto
rect information limit the efficacy of this system. Colour codardized pattern or marker and specific information (e.g.
ing of de
wristbands
facilitates rapid visual recognition of specific
dec_14_2005.pdf, acesso em 11 de junho
2006).
name and date of birth) could be written, or
de
2006.
issues, but the lack of a standardized coding system has lead
implementation of biometric technologies.
to errors by staff who provide care at multiple facilities (5).
OUTROS RECURSOS SELECIONADOS:
6. Edozien L. Correct patient, correct site, correct procedure. Safer Health Care, 27 de julho de 2005. http://
www.saferhealthcare.org.uk/NR/rdonlyres/6D89DBA84414-4092-9CF0-62BEBB80F8D8/0/shc_patientidentification.pdf.
7. Right patient—right care. Improving patient safety
through better manual and technology-based systems
for identification and matching of patients and their care.
Londres, National Patient Safety Agency, 2004 (http://
www.npsa.nhs.uk/site/media/documents/781_Right%20
patient%20right%20care%20final%20report.pdf, acesso
em 11 de junho de 2006).
2. McDonald CJ. Computerization can create safety
hazards: a bar-coding near miss. Annals of Internal Medicine, 2006, 144:510–516.
3. National Quality Forum (NQF) Safe Practices for
Better Health Care: http://www.qualityforum.org/projects/completed/safe_practices/
4. Poon EG et al. Medication dispensing errors and
potential adverse drug events before and after. Annals of
Internal Medicine, 2006, 145:426–434.