Correct patient identification is the cornerstone of patient safety in any healthcare setting. Misidentification of patients can occur at any location where healthcare is provided, such as hospital wards and outpatient clinics, laboratory and imaging departments and in primary healthcare clinics. The consequences of patient misidentification can result inappropriate management including investigations, diagnosis and treatment, with fatal consequences, for example, in a hemolytic transfusion reaction (1,2).
The Institute of Medicine publication, To err is human, reported an estimated 98,000 deaths annually in US hospitals resulting from preventable medical errors including medication and diagnostic errors (3). This led the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to introduce national patient safety goals (NPSG) to promote specific improvements in patient safety. Surveying healthcare organizations for implementation of the NPSG requirements is an integral part of Joint Commission (JC) inspections.
In 1989, the College of American Pathologists (CAP) introduced Q-Probes as indicators of laboratory medicine quality. Since 1991, numerous CAP Q-Probes to study wristband identification errors have been conducted. The mean wristband error rates, in hospitals, ranged from 5.5% to 8.4%. Quality improvement measures introduced by institutions have reduced patient wristband identification error rates to F1% (5–7).
The purpose of the study was to monitor patient identification wristband error rates detected during phlebotomy, and to evaluate the success of measures taken to reduce such errors.
The study was conducted at a 464 bed public sector tertiary care hospital between November 2006 and August 2010. Data was collected from inpatient wards where phlebotomy was performed by laboratory phlebotomists. Wards on which blood is collected by nurses or physicians, such as intensive care, pediatric intensive care and neonatal intensive care units were not included in the study. The emergency department, outpatient clinics and primary healthcare centers were excluded from the study.
During the period of this study, all patients at Tawam Hospital were identified by a printed, bar-coded wristband. Hospital policy dictates that patients shall be identified by two identifiers; the patient’s room or location are not acceptable identifiers. Furthermore, the specimen containers are labeled in the presence of the patient. The unique individual hospital number, name and date of birth are recognized patient identifiers. Bar coded wristbands are used at the institute. Phlebotomists are to bring any patient identification errors that are detected to the attention of the nurse in charge of the ward, and not to take blood from any patients in the presence of such errors.
The team conducted 80 unit based training sessions on patient safety issues and International Patient Safety Goals (IPSG) was included in the new employee orientation program since July 2008. Patient safety and quality fairs were conducted by the Department of Performance Innovation (responsible for all institutional quality matters). Educational videos on patient safety were screened by all staff, posters displayed throughout the hospital and a periodic newsletter was circulated to all employees to increase patient safety awareness. In addition, the safety team members conducted a number of audits addressing the IPSG including patient identification during the administration of medication; transfusion of blood and phlebotomy and sample labeling.
The total number of data points gathered and the breakdown of the error types are shown in Figure 1. The total baseline wristband error rates between November 2006 and February 2007 ranged from 10.6% to 16.5%. Between March 2007 and September 2007, error rates were 7.2%–16%, showing no significant improvement. Significant improvement was seen from September 2008 onwards, with error rates ranging from 0.4% to 1.5%. In the study conducted over 45 months, the absence of a wristband accounted for 50.3%–100% of errors, patient name and unique identification number errors accounted for 0%–24.6% and 0%–25.3% of errors, respectively.
Recommended strategies to identify and reduce wristband errors include: the creation and implementation of routine quality safety practices; continuous monitoring of reliable indicators; root cause analysis; the use of bar codes; phlebotomists not collecting blood from patients with wristband errors; education of healthcare professionals responsible for patient wristbands; interdisciplinary cooperation; addressing patient identification issues during orientation of new staff and continuous monitoring (1, 6).
Between November 2006 and September 2007, many of the above measure were implemented at our institution. Interdisciplinary cooperation, between the laboratory and nurses, and educational activities were insufficient and ineffective. This is reflected in no appreciable improvements in error rates during this period with the use of memos and reminders in the absence of teamwork and cooperation.
The significant improvement in error rates is linked to the introduction of the patient safety team and its initiatives as described above. Reduction in error rates has been sustainable between September 2008 and August 2010, despite no monitoring during March 2009 and February 2010. It can be inferred that the implementation of routine quality safety practices, due to the initiatives of the patient safety group and the hospital Department of Performance Innovation, is effective and sustainable.
The large number of measurements (77,153) made during 24 months, spanning a period of 45 months, would support that the data being presented is valid, and any reported improvement(s) should not be attributed to chance occurrence. Although patient wristband error rates between 0.2% and 0.3% as suggested by Howanitz et al. (6) were not obtained, the authors are confident that with continuous long term monitoring and educational activities, our institution will come close to achieving this target. We acknowledge a limitation of this study was that not all inpatient units, outpatient clinics, emergency departments and the three satellite establishments (two primary care centers; one hospital) were included.
Correct patient identification is the cornerstone of patient safety in any healthcare setting. With interdisciplinary cooperation, continuous monitoring and patient safety educational activities, patient wristband error rates can be reduced from 10.6% to 16.5% and sustained at levels of 0.4%–1.4%.
--Dhatt, G. S., Damir, H., Matarelli, S., Sankaranarayanan, K., & James, D. M. (2011). Patient safety: patient identification wristband errors. Clinical Chemistry & Laboratory Medicine, 49(5), 927-929. doi:10.1515/CCLM.2011.129
Reflection Exercise #6
The preceding section contained information
about patient safety. Write one case study example
regarding how you might use the content of this section in your practice.
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Excerpts from Bibliography referenced in this article
1. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V, et al. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med 2009; 47:143-53.
2. Lichtner V, Galliers JR, Wilson S. A pragmatics’ view of patient identification. Qual Saf Health Care 2010; (Suppl) 3:i13-9.
3. Kohn KT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press, 1999; 287pp
5. Renner SW, Howanitz PJ, Bachner P. Wristband identification error reporting in 712 hospitals. A College of American Pathologists’ Q-Probes study of quality issues in transfusion practice. Arch Pathol Lab Med 1993; 117:573-7
6. Howanitz PJ, Renner SW, Walsh MK. Continuous wristband monitoring over 2 years decreases identification errors: a College of American Pathologists Q-Tracjks Study. Arch Pathol Lab Med 2002; 126:809-15
7. Valenstein PN, Raab SS, Walsh MK. Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. Arch Pathol Lab Med 2006; 130: 1106-13