avestruz

Many hospital managers consider that they are correctly identifying their patients, that the possible error will be low, and that therefore they do not need a more secure identification system. That is something that would be good to have, but it is not a priority to acquire.

But this “feeling” is based on not having data about wrong identifications in their hospitals and the effects they have on the health of patients. But not because there are no errors, but because they are not measuring them. “If I do not have data about identification errors, it’s because they will not occur. In addition, my staff is very careful and always asks the patient’s name. ”

The fact that still only a minority of hospitals implements safe patient identification measures also influences this “feeling” of non-urgency in solving the problem. “If others are not already implementing it, will it be because the problem is not that serious?”

But simultaneously to this intentional superficial analysis (if there is no problem, there is no need to work and invest in a solution), most of the hospital professionals know some concrete cases of errors in identification with more or less serious consequences, although they are not reported.

That is, all health professionals are aware that there are errors in identifying patients, and assume that in some cases they lead to damage to the patient’s health. But they hide behind not having data so they do not consider it serious and do not look for a solution. “Out of sight, out of mind.”

This is not exclusive to the problems caused by identification errors. It also happens with the rest of the 9 types of errors that according to the WHO (World Health Organization) report on patient safety cause that the hospital processes themselves, despite being designed to heal us, cause adverse effects that harm the health of patients.

Why not measure the degree of occurrence of errors and the problems caused to the health of patients? There are some reasons, some of them of a cultural nature. The professional who makes a mistake does not feel comfortable reporting on it, he feels afraid. And not reporting on an error made by one of his colleagues, for fidelity.

Hospitals should implement anonymous and agile systems of alerts and reports on errors detected, training their staff about the need and ease of use. The awareness of hospital professionals is essential to understand that, as happens in other professional areas where human lives are at risk (as in a nuclear power plant, for example), the measurement of human errors is basic to get eradicated.

Of course this requires some work and investment in IT resources. In a large part of the hospitals these systems have not been implemented, and as a consequence there is no type of measurement or error data. That is, hospitals know of the existence of errors in hospital processes, but many do not implement processes to measure and control errors, to know how much and in what way it affects the health of patients. And they hide behind not knowing the concrete data to deny the importance of the problem. As a result, since there is no problem, they do not look for a solution.

And meanwhile the reality is that patients suffer damage to their health through hospital processes anonymously.

On the other hand, the errors that cause damage to the patient, as well as a safety problem for the patient, mean that the hospital has a higher cost due to the additional treatments. Therefore, there is no record of the money that the hospital loses because of the errors, and consequently they do not know how much money they would save with a solution.

Dr. Raymond D. Aller, from the University of Southern California, addresses this issue in a very clear way at his March 2016 conference at HIMSS in Las Vegas (https://www.himssconference.org/sites/himssconference/files/pdf/99.pdf). He considers that the people’s safety measures shouldn’t be only based on the economic cost payback. For instance, the seat belts in a car. The safety belt is not an extra that can be avoided to reduce costs.

Therefore, is it responsible not to incorporate a solution for errors that damage the patient’s health, and that we are sure we have in our hospital?