Effectiveness of implementing an improvement cycle in the identification of critically ill patients.
Maria Solange Moreira de Lima, Kauanny Vitoria Gurgel Dos Santos, Tâmara Taynah Medeiros da Silva and 5 others
PMID 35858025WHAT IT FOUND
A quality improvement programme improved patient identification most at the first re-check, with some slip at the second.
Education, protocol changes and new identification resources were delivered together, so their separate effects cannot be isolated.
Key findings
01Compliance with presence of an identification wristband rose from 50.00% to 85.71% at the first re-evaluation, and compliance with legible and correct wristband data rose from 32.69% to 73.47%.
02The sum of failures across the identification criteria fell from 200 at the initial assessment to 75 at the first re-evaluation, then rose to 111 at the second re-evaluation.
03The improvement cycle delivered several changes together, including protocol and standard operating procedure updates, nurse meetings and team training, and requests for new wristbands and bedside displays, so the effect of any single component cannot be separated.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study was done in one private hospital intensive care center in Brazil, so the results may not transfer to other settings. The sample was selected by convenience, with 52 patients in the initial assessment and 49 in the first re-evaluation, and there was no randomized or controlled comparison. The intervention changed several things at once, including protocol updates, education and identification resources, so the contribution of any single component cannot be separated. The outcomes were compliance with identification checks, not patient harm, medication errors, transfusion errors or other clinical events. Compliance improved most at the first re-evaluation and was lower at the second, so the gain may not be stable without continued effort. Some patients have legitimate exceptions to wristband checks, such as edema, injury or limb restriction, and the paper did not report how many exceptions occurred.
Declared interests
No funding source or conflict-of-interest declaration is stated in the supplied text.
The easy way to misread this
Do not read the improved compliance as proof that any single part of the programme works. The study had no control group, changed many things together, and measured identification checks rather than patient harm.