Identificação do paciente
Transcrição
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.