2021_Book_TextbookOfPatientSafetyAndClin

17 Patient Safety in Internal Medicine
219
Fig. 17.1 What
healthcare operators have
to do and not to do to
avoid patient
identification errors
Not
to do
do not use room
number, bed location
or diagnosis as
identifiers
To
do
Identify the patients
before any care
delivery
do not use closedended
questions
use double identifiers
do not mix up patients
with similar names
use open-ended
questions
do not assume that
another caregiver
already identifed the
patient
minimize noise and
interruptions during
identification
do not label containers
before obtaining a
sample or after
obtaining more
samples from more
patients
put patients with
similar name in
different locations of
the ward
label specimen
containers in presence
of patients
Use barcode systems
to minimize the risk,
especially in case of
invasive procedures or
high risk medications
crepancies, 1 in 3 patients have experienced a
diagnostic error (according to patients’ survey),
1 in 20 patients will experience a diagnostic error
every year (according to chart review). They are
the most common cause for malpractice claims
[21], and about half of physicians admit at least a
diagnostic error per month and perceive diagnostic
errors as the most dangerous (according to
physicians’ survey) [22].
The most commonly missed or delayed diseases
are: pulmonary embolism and drug reaction
or overdose (2.5%), lung cancer (3.9%),
colorectal cancer (3.6%), acute coronary syndrome
(3.1%), breast cancer (2.9%), and stroke
(2.6%) [23]. Physicians overestimate their diagnostic
ability: only 10% of clinicians admit they
performed any error in diagnosis over the past
year, but up to 40% of diagnoses about which cli-