Patient identification—a crucial aspect of patient safety - Patient Safety First

AORN Journal,  Sept, 2003  by Suzanne C. Beyea

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Identifying patients accurately presents many unique challenges in today's health care settings. First and foremost, error-proof systems have not been developed or implemented. Facilities have developed setting-specific solutions, but wide adoption of a single failsafe approach or solution has not occurred. The fast-paced nature of clinical settings may contribute to the difficulty clinicians and others experience in their efforts to correctly identify patients when providing care.

Concern for proper patient identification is evidenced in the 2003 National Patient Safety Goals. (1) One of the six identified goals is to improve the accuracy of patient identification. The related recommendations state that at least two patient identifiers, not including the patient's room number, should be used when blood samples are obtained or medications or blood are administered. The second recommendation relates to conducting a final verification during which active communication is used to confirm identity before the start of a procedure. (1)

NEAR MISSES AND ADVERSE EVENTS

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has issued several sentinel event reports that describe errors in patient identification. Classified as one type of wrong-site surgery incorrect patient identification has resulted in a patient undergoing an unnecessary procedure or surgery. In fact, a recent Sentinel Event Alert reported that, at that time, 13% of wrong-site surgeries involved surgery on the wrong patient. (2)

One such error was reported in an article titled "The wrong patient," in which the authors described a sequence of errors that led to health care personnel missing numerous opportunities to correctly identify a patient. (3) These errors resulted in the wrong patient--a 67-year-old woman--undergoing an invasive cardiac procedure. This adverse event was linked to absent or missed patient identification protocols and lack of informed consent.

Most fundamental nursing textbooks and courses describe the importance of verifying a patient's identity. This basic ritual and routine is integral to the medication administration process, treatments, and procedures. Student nurses learn to check a patient's identity during the intra-operative phases of care, such as when the patient is transferred to the holding area, OR, or postanesthesia care unit.

Despite this education, most nurses can describe a near-miss incident or actual adverse event in which a patient received a medication intended for another patient. An example of a near miss includes an event in which a patient was placed in the wrong OR suite or transferred to the OR without a name bracelet. Patients undergo tests, procedures, or surgery every day in health care facilities without anyone checking their name bracelet.

Why do these errors occur? No one is entirely certain. The Joint Commission reports that in the past seven years,

* communication,

* orientation and training,

* patient assessment, and

* availability of information were the four most common root causes for wrong-site surgery and all types of sentinel events. (4) These causes suggest the need for fail-safe systems that are highly reliable and error proof.

Despite multiple changes in the health care system during the past 30 years, most facilities continue to use a patient identification process and system that was developed at least three decades ago. Certainly no one providing care intends to incorrectly identify a patient. The systems clinicians use, however, create opportunities for error. For example, it is not uncommon to remove a patient's identification bracelet to insert an IV line or because the arm will be under the patient during the procedure. In the OR, patients' arms often are covered so the name bracelet is not easily accessible. During the procedure, the nurse may be relieved for a break, so the patient's identity cannot be verified easily other than by reviewing his or her chart.

In an effort to address identity issues in the OR, JCAHO has recommended a time-out before the start of surgery. The purpose of this time-out includes checking the type of procedure, surgical site and laterality, and patient identity. Despite these recommendations, errors and near misses continue to occur.

In fact, reports of near misses to AORN's Safety Net describe events in which nurses have observed or have been involved in patient identification problems. These issues include events in which multiple providers admitted they had not checked a patient's name band because they were in a hurry Nurses report having served a key role in the checks and balances process to identify patients. It is clear from the case reports related to identity that the causes of errors are multi-factorial and reside in complex systems.

CLINICAL RECOMMENDATIONS

All clinicians need to be concerned with the processes and systems that support correct identification of patients. An approach to ensuring a best practice for patient identification includes implementing a clearly written, easy-to-understand policy and procedure. To be fully implemented, the policy and procedure must be supported by available resources. For example, name bands will be removed for a variety of reasons; therefore, it is critical to have an adequate number of replacement bands and a easy process for a new bracelet to be stamped and applied.