After reading this article, you will be able to:
- Examine how Self Regional Healthcare identified patient ID errors
- Discuss strategies used to prevent patient ID errors
In 2007, as part of an annual performance improvement review, Leisa Butler, RHIA, CPHQ, performance manager in the quality management services department at Self Regional Healthcare (SRH) in Greenwood, SC, began tracking safety events occurring within the facility with an identification (ID) events team consisting of staff members from the operating room (OR), emergency care center (ECC), laboratory, and risk management department.
From this performance improvement review, Butler and her team discovered that patient ID events comprised the majority of safety events occurring at SRH. In targeting patient ID processes, SRH managed to reduce ID events by 65% after one month of implementing a new plan. These ID events included misidentification of a patient, specimen, medication, test results, and/or medical record.
“We conducted a common-cause analysis, and after looking at why the events occurred and the circumstances under which they occurred, we found that the vast majority of patient identification errors were in specimen IDs,” says Butler. “The specimens were either mislabeled or not labeled at all.” The specimen ID errors occurred on everything from blood to urine to tissue samples.
In addition to mislabeled or unlabeled specimens, the team found that incorrect patient ID numbers were being entered into the EKG machine. As a result, many hard copies of EKGs were mislabeled, which created confusion.
“Hard copies of the EKGs were stamped with the patient ID number and caused confusion at times because the hard copy sometimes would not get stamped or the ID numbers were illegible,” says Joie Rogers, performance improvement analyst at SRH. (See “EKG process” on p. 9 for a process map showing how SRH addressed this problem.)
Bar codes give edge and help with efficiency
Once the aforementioned problems were addressed, Butler and her team focused on preventing patient ID errors. Part of the solution came to Butler via ADMIN RX, an electronic device that scans the bar code on patient ID bands, then scans the medication and confirms the appropriateness of that medication based on pharmacy profiling.
This system essentially helps the nurse confirm that the correct patient is receiving the correct medication.
“We thought to ourselves, ‘Why can’t we use the scanners on ADMIN RX and give every patient an ID band with a bar code that confirms all the information and is usable for other scanner programs?’ ” says Butler.
Butler and her team developed a plan that would allow SRH to distribute bar codes to all patients, as well as provide a label for specimens being sent to different areas of the hospital. The team reviewed the cost of supplying the entire facility with bedside scanners and the kind of printer needed to print a scannable armband.
“Printers that would print labels for the ID armband were found. Scanners were purchased that would scan a patient’s ID band and generate a label with unique patient identifiers that could be placed on the specimen at the point of collection,” says Butler.
In the first month after implementation, SRH managed to reduce ID events by 65% just by implementing the new technology and using the scannable armbands and labels.
Clarifying delivery and ID
The team then analyzed the areas in the hospital from which specimens were coming and found that a vast majority of the specimen ID errors were occurring in the ED and the lab.
Butler and her team decided to map out the actual process of specimen collection in several areas in the hospital and examine how the specimens were sent and received in the lab. Primary areas of focus included the ECC, the OR, and preop testing.
“Things like where the patient received their bar-coded armband, who collected the specimen versus how and when it was labeled, and how the specimen was then sent on to the lab all varied depending on the area,” says Butler. “So as a team, we decided to come up with a core common process.” (See p. 10.)
In developing a common core process, the team decided that there could be no exceptions to key components. This decision was made to decrease the variability found during the initial assessment. However, the team also decided to allow specialty areas to add a step in the process if necessary. For example, in the OR, there are additional steps for processing and transferring specimens.
Along with that process, Butler and her team noted that steps could be added, but no steps could be left out during the processing or transferring of specimens.
“If an event occurs that deals with specimen labeling or ID labeling, then the standard flow chart must be reviewed, and it has to be noted where in the process things failed,” says Butler.
Butler concludes that the rollout of the new patient ID processes has been such a success because information was communicated and understood clearly by all staff members. “The staff was very receptive of the new processes,” she says.
Adapted from Briefings on Patient Safety, July 2009, HCPro, Inc.