Introduction: Reliable patient identification is essential for safe care, and failures may cause patient harm. Identification can be interfered with by system factors, including working conditions, technology, organizational barriers, and inadequate communications protocols. The study aims to explore systems factors contributing to patient identification errors during intrahospital transfers. Methods:We conducted a qualitative study through direct observation and interviews with porters during intrahospital patient transfers. Data were analyzed using the Systems Engineering Initiative for Patient Safety human factors model. The patient transfer process was mapped and compared with the institutional Positive Patient Identification policy. Potential system failures were identified using a Failure Modes and Effects Analysis.Results: A total of 60 patient transfer handovers were observed. In none of the evaluable cases observed, patient identification was conducted correctly according to the hospital policy at every step of the process. The principal system factor responsible was organizational failure, followed by technology and team culture issues. The Failure Modes and Effects Analysis methodology revealed that miscommunication between staff and lack of key patient information put patient safety at risk. Conclusions:Patient identification during intrahospital patient transfer is a high-risk event because several factors and many people interact. In this study, the disconnect between the policy and the reality of the workplace left staff and patients vulnerable to the consequences of misidentification. Where a policy is known to be substantially different from work as done, urgent revision is required to eliminate the serious risks associated with the unguided evolution of working practice.

BackgroundCurrent PPE practices in UK intensive care units involve “sessional” gown use. This protects staff, but puts patients at risk of nosocomial infection via PPE gowns. Anecdotal reports of such infections in ITUs during Covid are frequent. We therefore explored the use of short-sleeved gowns with hand and arm hygiene as an alternative to sessional gowns.MethodsITU Staff were invited for simulation suite training in Covid intubation and proning. They were trained in a specific hand and arm washing technique before performing simulated tasks using both standard and modified (short sleeved) PPE. Fluorescent powder was used to simulate micro-organisms, and detected using standardised photos under U/V light. Teams of staff were randomised to use standard or modified PPE first. Individuals were questioned about their feeling of personal safety, comfort and the patient’s safety at 4 intervals.Results68 staff and 17 proning volunteers were studied in 17 sessions. Modified PPE completely prevented staff contamination during Covid intubation, which occurred in 30/67 staff wearing standard PPE (p = 0.0029, McNemar). Conversely, proning volunteers were contaminated by staff in 15/17 sessions with standard PPE and in 1/17 with modified PPE (P = 0.0227 McNemar). Impressions of staff comfort were superior with modified PPE (p< 0.001, t-test); personal safety scored higher with standard PPE, but the difference decreased during the session (p<0.001 start, 0.068 end). Impressions of patient safety were initially similar (p=0.87) but finished strongly in favour of modified PPE (p<0.001).ConclusionsModified PPE using short sleeves and hand/arm cleansing appears superior to standard PPE with sessional gowns in preventing transfer of contamination between staff and patients. A clinical trial of this strategy is merited.

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