Podcast
Questions and Answers
What method should be used for identifying patients who are confused or in a coma?
What method should be used for identifying patients who are confused or in a coma?
Which of the following is a recommended practice for labeling specimen containers?
Which of the following is a recommended practice for labeling specimen containers?
What should health-care workers be trained on regarding patient identification?
What should health-care workers be trained on regarding patient identification?
What communication method should involve a write-down and read-back of patient identity?
What communication method should involve a write-down and read-back of patient identity?
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What is a key action to prevent the automated multiplication of computer entry errors?
What is a key action to prevent the automated multiplication of computer entry errors?
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What can patient identification errors lead to?
What can patient identification errors lead to?
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Which professional is least likely to make a patient identification error?
Which professional is least likely to make a patient identification error?
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What is a primary cause of patient identification errors?
What is a primary cause of patient identification errors?
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During which healthcare processes can patient identification errors occur?
During which healthcare processes can patient identification errors occur?
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What role do patient identification errors play in patient safety?
What role do patient identification errors play in patient safety?
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Which of the following is a consequence of a wrong-patient error in healthcare?
Which of the following is a consequence of a wrong-patient error in healthcare?
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What is a notable example of a wrong-patient error described?
What is a notable example of a wrong-patient error described?
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Which situations can contribute to patient identification errors?
Which situations can contribute to patient identification errors?
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Which of the following is NOT considered an acceptable patient identifier?
Which of the following is NOT considered an acceptable patient identifier?
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What is a key benefit of using wristbands for patient identification?
What is a key benefit of using wristbands for patient identification?
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Which of the following limitations of wristbands can contribute to patient misidentification?
Which of the following limitations of wristbands can contribute to patient misidentification?
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What is the primary purpose of a patient identifier?
What is the primary purpose of a patient identifier?
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What risk is associated with non-standardized color coding of wristbands?
What risk is associated with non-standardized color coding of wristbands?
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What is an example of technology used for enhancing patient identification?
What is an example of technology used for enhancing patient identification?
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Which of the following is NOT a limitation of wristbands?
Which of the following is NOT a limitation of wristbands?
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What environmental factors might contribute to patient misidentification?
What environmental factors might contribute to patient misidentification?
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What is a key factor in minimizing wrong-patient events?
What is a key factor in minimizing wrong-patient events?
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Which scenario illustrates a wrong-patient event?
Which scenario illustrates a wrong-patient event?
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In which step of the patient journey are misidentification errors likely to occur?
In which step of the patient journey are misidentification errors likely to occur?
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What was the consequence of the wrong patient being marked deceased in a doctor's office?
What was the consequence of the wrong patient being marked deceased in a doctor's office?
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What issue arose when two patients with the same first name were scheduled at an eye clinic?
What issue arose when two patients with the same first name were scheduled at an eye clinic?
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What potential risk is associated with surgical procedures in hospital settings?
What potential risk is associated with surgical procedures in hospital settings?
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What is a common cause of choking in hospital patients related to dietary errors?
What is a common cause of choking in hospital patients related to dietary errors?
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What is a fundamental step that begins the patient journey?
What is a fundamental step that begins the patient journey?
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What is a primary responsibility of healthcare workers regarding patient identification?
What is a primary responsibility of healthcare workers regarding patient identification?
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Which of the following is NOT a limitation or risk associated with barcodes?
Which of the following is NOT a limitation or risk associated with barcodes?
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What is one benefit of using barcodes for patient identification?
What is one benefit of using barcodes for patient identification?
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What is a common biometric approach used for patient identification?
What is a common biometric approach used for patient identification?
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What should be used as identifiers for verifying a patient’s identity?
What should be used as identifiers for verifying a patient’s identity?
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Which technology uses radio frequency to transfer data for patient identification?
Which technology uses radio frequency to transfer data for patient identification?
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Which of the following statements about the limitations of barcodes is true?
Which of the following statements about the limitations of barcodes is true?
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What is a recommended practice to standardize patient identification across healthcare facilities?
What is a recommended practice to standardize patient identification across healthcare facilities?
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What is a primary risk associated with incorrect documentation during patient registration?
What is a primary risk associated with incorrect documentation during patient registration?
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At what point can a procedure, medication, or treatment be incorrectly tied to a patient?
At what point can a procedure, medication, or treatment be incorrectly tied to a patient?
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Why was there confusion regarding Patient Alex and Patient Oscar during their transfusion process?
Why was there confusion regarding Patient Alex and Patient Oscar during their transfusion process?
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What was the ultimate consequence of the blood transfusion error for Patient Oscar?
What was the ultimate consequence of the blood transfusion error for Patient Oscar?
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What protocol did the Blood Bank follow mistakenly in relation to the blood specimen?
What protocol did the Blood Bank follow mistakenly in relation to the blood specimen?
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What should have been done before starting the blood transfusion for Patient Oscar?
What should have been done before starting the blood transfusion for Patient Oscar?
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What key factor contributed to the error in blood transfusion for Patient Oscar?
What key factor contributed to the error in blood transfusion for Patient Oscar?
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What should be a specific point of concern in any patient care process?
What should be a specific point of concern in any patient care process?
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Study Notes
Patient Identification Errors
- Patient identification is the process of correctly matching a patient to the intended interventions and communicating accurate and reliable information throughout the patient's care.
- Errors in patient identification can occur due to unclear patient identity or unclear intended care (e.g., procedures, treatments, medications).
- Most wrong-patient errors are preventable.
- Incorrect patient identification can happen during multiple procedures, such as registration, electronic data entry, medication administration, medical interventions, blood transfusions, diagnostic testing, monitoring, and emergency care.
- Mistakes can occur across various healthcare settings, from hospitals to physician offices and pharmacies.
- No healthcare professional is immune to making wrong-patient errors.
- Many patient identification errors affect more than one person.
Patient Safety
- Misidentification leads to incorrect treatment plans, medications, or transplants.
- The effects of misidentification can range from financial loss to physical harm, even death in some cases.
- Specific examples of wrong-patient events include medication errors, surgical procedures given to the wrong patient, and mistakes in receiving and administering blood transfusions.
Minimizing Errors
- Each patient must be uniquely identified.
- Each procedure, treatment, or medication must be uniquely identified.
- The patient journey involves steps from admission to discharge, sometimes occurring in parallel.
Patient Identification Errors in the Patient Journey
- At each step of the patient journey, a new set of care providers is engaged.
- Each step uses a different system (e.g., x-ray, surgery).
- New information is received, requested, or generated for each interaction.
Key Points for Maintaining Patient Identity
- Patients' identities must be correctly documented.
- Errors often occur during initial registration with incorrect identifiers (e.g., medical record numbers).
- Patient transfers from one location or practitioner to another (e.g., operating room) can present risks.
- Incorrect patient procedures, medication or treatments, occur when the procedure isn't correctly tied to the right patient.
A Case Study:
- Two patients with the same name and date of birth were admitted to the hospital.
- A physician ordered a transfusion for one patient, but the medical resident mistakenly drew blood from the other patient.
- The Blood Bank released the wrong blood type, leading to a serious error that was only detected by a routine query.
Environmental Factors Contributing to Misidentification
- Crowded waiting rooms with multiple beds.
- Lack of barcodes scanners when working with blood products.
- Laptops or scanners failing to work appropriately.
- Errors in patient armband information.
Patient Factors Contributing to Misidentification
- Patients unable to identify themselves, such as children.
- Patients with communication difficulties.
- Patient with cognitive impairment.
- Patients with similar names.
- Patients with limited language proficiency or English.
Cultural Factors Contributing to Patient Misidentification
- Informal norms that bypass barcode scanning.
- Not using two identifiers during patient handoffs.
- Possible misperception in not labeling blood tubes in the bedside area.
- Absence of double checks when identifying blood products.
- Patient responses of "yes" when prompted about patient identity as positive or confirming of identity.
Patient Identifier
- A patient identifier is information directly associated with an individual.
- It reliably identifies the person for whom service or treatment is intended, such as name, ID number, date of birth, or other specific identifiers.
- A room number is not considered a unique patient identifier.
Electronic Identification Technology
- Barcodes and Radio Frequency Identification (RFID) tags can be used for patient identification, including coding.
- Armbands are one source of identifying information, but not unique identifiers.
- It is the information itself being tracked that is the identifier, and not the medium on which the information is stored.
Wristbands
- Wristbands are plastic identification bracelets used in hospitals and clinics for patient identification.
- Wristbands usually contain basic information like names and dates of birth, sometimes colour-coded for special conditions like allergies or diabetes.
- Wristbands are portable, have clear information, and are easy to attach or use.
- Wristband limitations may include their limitations in fitting to various body types, being difficult to attach or prone to damage.
Barcodes
- Barcodes are used for patient identification, containing machine-readable information.
- Barcodes may be 1D or 2D, and can contain patient information that can be stored through the wristband.
- Barcodes often use an inexpensive method of encoding text information, and can be easily read by inexpensive electronic readers.
Radio Frequency Identification (RFID) Tags
- Radio frequency identification (RFID) is a system that uses radio waves to transfer data between a reader and a tag, such as an RFID tag attached to a patient.
- Biometric devices use automated methods to identify a person based on physiological characteristics, like fingerprints, facial recognition or iris scan.
Quiz 1 and 2
- Quiz 1 asks about patient identifiers and their examples.
- Quiz 2 asks for three ways to prevent patient misidentification errors.
How to Ensure Accurate Patient Identification
- Key aspects of preventing errors.
- Importance of correct patient identification and respecting privacy concerns.
- Clear protocols for distinguishing patients with the same name.
- Standard patient identification approaches.
- Protocols for handling patients that lack identification, and those who are confused or comatose.
- Protocols for handling blood and specimen identification.
- Training in checking and confirming patient identity.
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Description
This quiz focuses on the critical issue of patient identification errors within healthcare settings. It examines how misidentification can lead to significant treatment mistakes and highlights the need for reliable patient matching processes. Understanding these errors is essential for improving patient safety and ensuring proper care delivery.
