Patient Identification Errors PDF

Patient identification errors Ass. Prof Nesrine Saad Farrag Community medicine Department Port Said University Patient identification It is the process of correctly matching a patient to appropriately intended interventions and communicating information about the...

Patient identification errors Ass. Prof Nesrine Saad Farrag Community medicine Department Port Said University Patient identification It is the process of correctly matching a patient to appropriately intended interventions and communicating information about the patient’s identity accurately and reliably throughout the continuum of care. Patient identification errors can be characterized as being caused by: The identity of the patient not being clearly established, such as when one patient is mistaken for another, and / or The nature of the intended care (including procedures / treatments / medications) is not clearly established, which may result in the correct procedures / treatments / medication not being applied to the correct patient.  Patient identification errors are particularly troublesome for several reasons Most, if not all, wrong-patient errors are preventable. incorrect patient identification can occur during multiple procedures and processes, including but not limited to patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and emergency care. patient identification mistakes can occur in every healthcare setting, from hospitals and nursing homes to physician offices and pharmacies. no one on the patient’s healthcare team is immune from making a wrong-patient error. Mistakes have been made by physicians, nurses, lab technicians, pharmacists, transporters, and others. Many patient identification errors affect at least two people. For example, when a patient receives a medication intended for  Patient identification errors jeopardize patient safety If a patient is misidentified, they will be given wrong treatment plans, wrong medications, or even wrong transplants. While the damages range from financial to physical, the effects are irreversible in most cases, with some patients even losing their lives.  Sample Wrong-Patient Events from ECRI Institute Patient Safety Organization Database Medical-surgical unit: a patient in cardiac arrest was mistakenly not resuscitated because the care team pulled up the wrong patient’s record and adhered to a do-not-resuscitate order. Surgery: a cardiac clearance meant for a different patient was given to a patient who previously had an abnormal electrocardiogram. The patient underwent surgery and was found unresponsive in his hospital room the next day.  Sample Wrong-Patient Events from ECRI Institute PSO’s Database Dietary: the wrong meal tray was given to a patient with a nasogastric tube who was not to receive any food or fluids orally. the patient attempted to eat the food and choked. Diagnostic imaging: the wrong patient was taken to the radiology department for a magnetic resonance imaging exam with general anesthesia. The patient was intubated and sedated before the error was caught.  Sample Wrong-Patient Events from ECRI Institute PSO’s Database Maternity ward: an infant received another infant’s breastmilk. the mother who produced the breastmilk was infected with the hepatitis b virus, so the infant had to be treated with hepatitis b immune globulin. Doctor’s office: the wrong patient was marked as deceased in the doctor’s office’s electronic health record. all her outstanding appointments were automatically cancelled. When the patient arrived for a previously scheduled appointment, she was not happy that all her appointments had been cancelled. Eye clinic: two patients with the same first name were scheduled For these errors to be minimized: Every patient must be uniquely identified in an unambiguous manner. Each procedure / treatment / medication must be uniquely identified in an unambiguous manner.  The Patient Journey When individuals enter a clinical care setting, they commence a series of steps along a continuum of patient care that is described as the ‘patient journey’. The steps in the patient journey are usually sequential but can often occur in parallel (and can sometimes be repeated within the same journey). The journey begins with patient admission and usually concludes with discharge. In between these two episodes, the patient and the healthcare facility systems interact: care procedures are performed, and information is produced and recorded. At critical steps in the patient journey, there are points where these processes are vulnerable to patient misidentification.  At each new step in the patient journey the individual (and the information about them) engages with: A new set of care providers. For example, the triage nurse passes care over to the registrar who then admits the patient. Admission is processed and recorded by clerical and nursing staff. A new system. For example, the patient is moved from emergency to the ward, at some point going via the x-ray department. Subsequently, the individual undergoes surgery and receives medication. These processes often have their own, specific, information systems. New information. With each new engagement, documentation relating to the care of the individual is received, requested, and/or generated. Based on this information or documentation, decisions about the individual’s care are made and processes are initiated. Particular points of concern are those where: A patient’s identity is not correctly documented. This will typically occur upon initial registration where the patient is linked to an incorrect medical record number or other identifier. A patient is moved from one location to another or from one practitioner or treatment team to another, (e.g. from ward to operating theatre). A procedure / medication / test / treatment is not tied to the correct patient. This can occur at the point of requesting a procedure / medication / test / treatment, at the point of applying the procedure / medication / test / treatment, or at the point of returning the  A Case study Patient Alex and Patient Oscar were both admitted to the same medical unit, on the same day. They had the same last name and date of birth. Alex’s blood type was A- positive and Oscar’s blood type was O-positive. The physician ordered a transfusion for Patient Oscar. The medical resident went to Patient Alex’s room with an empty vial and drew the blood specimen. Patient Alex was dozing off and not paying much attention. Then, the resident proceeded to the nurses’ station and asked the nurse to label the tube with Patient Oscar’s information while she completed the blood request form. Once complete, both the resident and nurse signed the form. Then, the clerk transported the specimen and form to  A Case study The Blood Bank processed the specimen according to standard protocol. They did not have a historical blood type on file for Patient Oscar, since he was a new patient to the hospital. Based on the appropriate processing results, the Blood Bank released a unit of A-positive blood to the medical floor. The unit nurse along with another nurse hung the A-positive blood at the patient’s bedside. Before starting the transfusion, the nurse casually asked the patient “so, what’s your blood type again?” Patient Oscar responded “O- positive.” At that moment, both nurses realized the significant error; an A-positive bag of blood was hanging at the bedside. They immediately removed the blood before the transfusion was started and notified the medical resident and the Blood Bank. Upon further investigation, the medical resident discovered that she had drawn the blood from the wrong patient. Environmental factors that contribute to patient misidentification Patient factors that contribute to patient misidentification Cultural factors that contribute to patient misidentification  A patient identifier It is "Information directly associated with an individual that reliably identifies the individual as the person for whom the service or treatment is intended. Acceptable identifiers may be the individual's name, an assigned identification number, telephone number, date of birth or other person-specific identifier (e.g. medical record number, etc) Use of a room number would NOT be considered an example of a unique patient identifier.  Electronic identification technology coding, such as bar coding or RFID, that includes two or more person-specific identifiers Armbands An armband in and of itself is not a patient identifier, rather an example of a source where patient identification information may be located. It is the person-specific information that is the "identifier," not the medium on which that information resides. OVERVIEW OF CURRENT AND EMERGING TECHNOLOGIES Wristbands The wearing of plastic identification bracelets (wristbands) is the accepted practice for patient identification. The information on the patient wristband varies but usually includes, at a minimum, full name, date of birth, and hospital number. Wristbands are sometimes color- coded to indicate special conditions, such as allergy, pregnancy, diabetes, and so on. Benefits: Portable, Cheap, Legible to all parties, medical and nursing staff, patients, and relatives, Generally easy and quick to attach, Widely accepted.  Wristbands Limitations / Risks: Can be difficult to fit to newborns, obese patients, patients with an allergy to plastic. Wrong wristband can be attached to patient. Missing or incorrect information can lead to misidentification. Colour coding is not standardized at present and varies from one setting to another,sometimes resulting in confusion for staff. Easy to remove or fall off. Illegible when not printed correctly or with printing that is difficult to read. Vulnerable to damage by contact with water or other liquids. Difficult to apply in some medical conditions or treatments.  Barcodes Barcoding, using adjacent bars and spaces to present information, is the most familiar form of identification (ID) coding technology. Attached to a wristband, identifying information about the patient and their care may be contained in or accessed through the machine-readable barcode on the wristband. Benefits: Simple to use. Well known 1-D barcode technology; 2-D barcodes are reasonably well known. Inexpensive method of encoding text information. Easily read by inexpensive electronic readers. Data can be collected rapidly. Barcodes Limitations / Risks: Barcode reader requires line of sight. Illegible to staff, patients, and relatives; thus, misidentification not readily recognized manually. Limited data capacity, especially with 1-D barcodes. Requires the reader machine to be located with patient: implications for space, portability, mobility, and convenience. Cost. While having a low unit cost, the number of readers required to give ready access over an entire establishment can be significant.  Radio Frequency Identification Tags Radio frequency identification (RFID) uses radio frequency transfer of data between a reader and a tag. The tag can be attached to the wristband or inserted under the skin. Biometric Devices Biometric devices use automated methods of identifying or authenticating a living person based on physiological or, less commonly, behavioral characteristics. common biometric approaches include the recognition of fingerprints or thumbprints, hand or palm geometry, the retina, the iris, or facial characteristics. Quiz 1 What is a patient identifier? Give examples How to ensure accurate patient identification and hopefully eliminate the occurrence of these preventable events?  Emphasize the primary responsibility of health-care workers to check the identity of patients and match the correct patients with the correct care (e.g. laboratory results, specimens, procedures) before that care is administered. Encourage the use of at least two identifiers (e.g. name and date of birth) to verify a patient’s identity upon admission or transfer to another hospital or other care setting and prior to the administration of care. Neither of these identifiers should be the patient’s room number.  Standardize the approaches to patient identification among different facilities within a health-care system. For example, use of white ID bands on which a standardized pattern or marker and specific information (e.g., name and date of birth) could be written, or implementation of biometric technologies How to ensure accurate patient identification and hopefully eliminate the occurrence of these preventable events? Provide clear protocols for identifying patients who lack identification and for distinguishing the identity of patients with the same name. Non-verbal approaches for identifying comatose or confused patients should be developed and used. Encourage the labeling of containers used for blood and other specimens in the presence of the patient. Provide clear protocols for maintaining patient sample identities throughout pre-analytical, analytical, and post-analytical processes. How to ensure accurate patient identification and hopefully eliminate the occurrence of these preventable events? Provide clear protocols for questioning laboratory results or other test findings when they are not consistent with the patient’s clinical history. Provide for repeated checking and review in order to prevent automated multiplication of a computer entry error. Incorporate training on procedures for checking/verifying a patient’s identity into the orientation and continuing professional development for health-care workers. How to ensure accurate patient identification and hopefully eliminate the occurrence of these preventable events? Educate patients on the importance and relevance of correct patient identification in a positive fashion that also respects concerns for privacy. Write-down and read-back of the patient’s identity should take place during phone communication about a patient. Active identification (asking patient to state his or her name) should be used during all verbal communications with the patient; passive identification should be avoided Quiz 2. List 3 ways to prevent patient misidentification errors?