From case studies to guidelines to technological advances, EndoNurse takes at a look at patient identification initiatives in the 21st century.
A study conducted in 2002 examined the case of a patient who was mistakenly taken for another patient’s invasive electrophysiology procedure.1 After reviewing the case and the results of the institution’s root-cause analysis, it was discovered that at least 17 distinct errors occurred. The researchers note that one of the most remediable of these were absent or misused protocols for patient identification.
In an analysis of major transfusion errors reported to the Food and Drug Administration (FDA) over a 10-year period from 1976 to 1985, 10 patient deaths were found in which the actual and intended patients shared the same last name, and five deaths were found to coincide with sharing the same hospital room.2
Moreover, a random sample of 60 patients in a Chinese hospital were selected to see if their full names were shared with other patients attending the same hospital.3 A total of 32 of the 60 sampled patients (53 percent) shared a common full name with one to 101 other patients attending the same hospital. Name confusion and mistaken identity is “especially relevant in communities where most people’s names are not unique,” the researchers point out.
A study conducted at the Veterans Affairs Medical Center in West Los Angeles, Calif., compared wristband identification errors for 712 hospitals.4 Phlebotomists checked patient wristbands on 2,463,727 occasions, finding 67,289 errors. Ten percent of the hospital participants had error rates of 10.9 percent or greater. The researchers found patient wristbands were missing entirely in 33,308 instances — which represented 49.5 percent of errors. Multiple wristbands with different information occurred 8.3 percent of the time; wristbands with incomplete data 7.5 percent; erroneous data 8.6 percent; illegible data 5.7 percent; and patients wearing wristbands with another patient’s identifying information occurred 0.5 percent of the time.
In a similar study conducted at the State University of New York, Downstate Medical Center in Brooklyn, N.Y., wristband error rates were tracked over a two-year period.5 Each institution’s phlebotomists inspected wristbands for errors before performing phlebotomy procedures and recorded the number of patients with wristband errors. On a monthly basis, data was submitted to the researchers.
During the two years, 1,757,730 wristbands were examined, and 45,197 wristband errors were found. The mean wristband error rate for the first quarter was 7.4 percent. However by the eighth quarter, the mean wristband error rate had fallen to 3.05 percent; showing continuous improvement while enrolled in the program.
The resounding suggestion for improvement provided by the largest number of best and most improved performers was that phlebotomists should refuse to perform phlebotomy on a patient when a wristband error is detected. The results of the two studies left researchers with the conclusion that wristband identification error rates depend on differences in hospital policy and procedure. This is because during each study, the implementation of monitoring for errors by phlebotomy staff was found to be the most important policy associated with lower error rates.
Patient identification errors have sparked safety initiatives worldwide. For example, there are those set forth by the Joint Commission on Accreditation of Healthcare Organizations (JACHO). The No. 1 component of the 2005 JACHO National Patient Safety Goals is to improve the accuracy of patient identification. JACHO recommends healthcare workers “use at least two patient identifiers — neither to be the patient’s room number — whenever administering medications or blood products; taking blood samples and other specimens for clinical testing; or providing any other treatments or procedures,” the literature reads.
Patti Zidlicky, RN, MBA, project director with the Joint Commission International Center for Patient Safety, explains, “The intent of National Patient Safety Goal 1, Requirement 1A is twofold: First, to reasonably identify the individual as the person for whom the service or treatment is intended, and second, to match the service or treatment to that individual.”
Using two identifiers improves the reliability of the patient identification process.6 The use of two identifiers also helps ensure that a correct match is made between the service or treatment and the individual. Therefore, each of the two patient-specific identifiers must be directly associated with the individual.
According to JCAHO, acceptable identifiers include:
- The individual’s name
- An assigned identification number
- Telephone number
- Date of birth
- Social Security number
- Other person-specific identifiers
A directive from the U.S. Department of Veterans Affairs (VA) addresses correct patient identification by requiring that operating room (OR) staff ask the patient to state — not confirm — his or her name, full Social Security number or date of birth, and the procedure site just before entering the OR.6 The patient’s responses must then be checked against the patient’s identification wristband, consent form, and other documents, and the marked site.
“Do not solely rely on patients to correctly identify themselves,” reads the guidelines of one United Kingdom hospital’s patient ID policy.7 “Some patients will agree to absolutely anything you say to them.” In addition, patients can give more than one name and date of birth — especially non-English speakers.
Zidlicky points out that staff sometimes mistakenly bypasses patient identification because they already “know” the patient. “Staff needs to recognize that patient identification is one way to prevent medical errors and improve patient safety,” she asserts.
Lee Ann Johnson, BS, BSN, RN, clinical director and administrator of San Antonio, Texas-based Sonterra Endoscopy Center, shares the policies her center performs on patient identification.
“As soon as a patient walks into the facility, we ask them to look over the labels used to put on their paperwork and make sure all information is correct. They go to pre-op where we review their wristband to verify their information to be correct and ask them what they understand as to the reason they are having the procedure done. We have laminated bright colored 4-by-5 cards that each physician is assigned to that are placed on the IV pole at the head of the bed at the time the patient is placed in the bed. Each card has in bold letters what procedure the patient is having and who the physician is. When the tech comes to get the patient all they have to do is look at the card and they know whose patient it is and what is being done.
“The tech verifies with the patient who they are before taking them into to the procedure room. When the patient arrives to the procedure room and before the nurse begins to administer medications, she looks at the consent, asks the patient to identify himself or herself and what they are having done, and both the tech and nurse look at their wristband.”
“Communication is the key,” she explains. “Never assume you know everything.”
Johnson says their biggest problem occurs when the front office gets information from the doctor’s offices to schedule, and information often is missing. “So I have had to be diligent in reminding them to have the patients verify their information,” she says.
She continues, “We have a lot of wrong sex and spelling of names, but have been fortunate not to have a mix-up with a patient and the actual procedure to be done. We have monthly staff meetings and if I see a trend, then that is an area discussed. I also stress the importance of checking all paperwork and asking the patients questions in order to eliminate mistakes.”
- ECRI offers the following advice on properly identifying patients:6
- Adopt and implement policies and procedures that require the use of at least two person-specific patient identifiers, exclusive of patient room numbers.
- Encourage the reporting of patient identification errors and near-misses.
- Ensure that patient identification protocols comply with applicable accreditation organization goals and standards, state regulations (if applicable), and professional society guidelines.
- Avoid placing patients with the same or similar sounding last names in the same room.
- Post “name alerts” in multiple visible locations commonly used by nurses, students, residents, and attending physicians.
- Discourage the removal of patient identification wristbands unless removal cannot be avoided.
- Implement a zero-tolerance policy for blood samples and pathology specimens that have missing or incorrect patient identifiers.
- Consider implementing new technologies for patient identification.
- Perform a proactive risk assessment for patient identification systems, particularly if new technology, such as bar coded wristbands, has been introduced.
- Monitor compliance with patient identification policies and procedures through direct observation.
Other suggestions include avoiding placement of the identification wristband on a patient’s affected side and promptly replacing wristbands that must be removed during a procedure. In circumstances in which it is not feasible to place an identification wristband on the patient, a specific procedure should be in place and implemented for patient identification.
The UK hospital aforementioned includes messages on the proper usage of addressograph labels as well. The wrong addressograph label placed on a request form, a referral form, a medication chart or a consent form has potentially catastrophic consequences for a patient, the document points out.7 The policy advises all staff to “make doubly sure” that the addressograph label they are using relates to the correct patient. In addition, the document strongly advises against walking around with the addressograph labels of several patients on their uniforms or attached to other places.
Recent technology offers viable solutions to many of these patient identification-related medical errors.8 Computer-based medical records, integration with the pharmacy, decision support software, computerized physician order entry systems, bar coding, and radiofrequency identification (RFID) technologies all offer ways to avoid tragic treatment outcomes.
Most scenarios for patient identification involve the substitution or supplementation of the traditional wristband for one with a unique bar code patient identifier.2 All patient specimens, medications, and released blood products then receive the patient’s unique bar code ID. No procedure or treatment can occur unless the patient’s ID is scanned with a portable scanner and matched with a bar code generated by the doctor’s order. For example, a phlebotomist would carry the scanner, check the patient’s ID against a bar coded specimen label or collection list, and draw blood only in the event of a match. Similarly, for administration or treatment, the patient’s ID and the intended therapeutic would be scanned at the bedside with a portable reader. If a match exists, the transfusion or medication is allowed and the time and date are recorded. The data is then transmitted directly to the hospital computer system. The nurse’s bar code ID can also be scanned and a timed administration record can be created. If there is no match, an alarm is sounded, and the administration will be delayed until the problem can be resolved.
“The reports from organizations such as the Institute of Medicine and HealthGrades have crystallized attention on both the human and economic cost of medical errors,” says Ralph Moher, director of corporate marketing and communications, General Data Company. “These reports have emphasized the importance of patient safety and the need for bar code technology from the bedside to the boardroom. The industry has shifted from asking the question ‘Is there a problem?’ and now demonstrates a renewed commitment to making a difference. Identifying the causes of medical errors is complex. Eliminating the reliance on oral and handwritten communication, along with minimizing transcription, translation, and interpretation of physician orders, are potential mechanisms for reducing errors.”
According to Moher, currently about 5 percent of hospitals utilize barcode technology for patient identification. “Barcode technology is catching on, but it is not as widespread as it is in other industries. We currently track steering wheels better than we track hospital patients,” he points out.
Ramona Douglass, AMS, senior bar code manager with Precision Dynamics Corporation (PDC) says her company recommends that one of the two patient identifiers spelled out by JACHO be a machine-readable bar code on a patient wristband.
PDC’s bar code systems solution team, in conjunction with Houston Medical Center, conducted a study in which a pointof- care bar code system was implemented and consisted of Citizen 521 Printers, PDC ScanBand Wristbands, AccuCheck Handheld Glucose Meters, and a Meditech Laboratory Information System (LIS). During the first three months of implementation, Houston Medical Center reduced information systems errors by 30 percent. (For more information on the case study, visit www.pdcorp.com/healthcare/case_houston.html.) “Bar coding systems that enable auto-identification of patients can reduce medical errors, improve productivity, curb fraud, and greatly enhance patient safety,” Moher affirms.
Johnson, who also works in an emergency room on the weekends, says she has found that “even the barcodes are not always 100 percent correct with patient identification.” However, prior to bar coding, processes involved keystroke entry of identification numbers that produce approximately one error in every 300 entered characters.2 In contrast, bar coding produces misidentification errors at rates ranging from one character in 15,000 to one character in 36 trillion.
According to ECRI, the areas in which barcode technology shows promise for improving patient safety includes:2
- Patient identification
- Medication dispensing and administration
- Specimen handling
- Medical record keeping
General Data developed a family of durable wristbands that allow hospitals to incorporate multiple forms of identification directly on the face of the wristband. The Personal ID wristbands are designed specifically for error-free bar code and photo identification of patients in hospitals and other healthcare environments.
“As a result of incorporating multiple identifiers, hospitals and other healthcare providers can greatly improve their patient identification processes to help eliminate errors, reduce costs, enhance patient care, address regulatory requirements, and prevent fraud,” Moher says.
Health Care Logistics offers RxScan/HCL verification and error prevention software/hardware for improving the accuracy of patient identification. The hub of the system is the RxScan Ultra® Point of Care Scanner System. According to Ken Bober of HCL and Max Peoples of RxScan, the product can be used to identify patients by either scanning their wristband or by looking up identifying information using their name or identification number. The portable scanner then displays on its color screen other identifying information for the patient.
“The system provides at the least, the two patient identifiers — and more, depending upon site-specific needs — required to be used whenever administering medications or blood products, taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures,” Bober and Peoples explain.
All of these systems range in price, size, and capabilities. Whether or not to implement such technologies depends on each facility’s standards and budget.
Moher concludes, “Regardless of the type of medical facility, patients are required to check in and receive some form of a patient identification tag. Wristbands have been used in hospitals for decades.”
Now, it is your turn to make sure they are safe.