Team works to make patient identification errors "never events"

Lisa Pannella, RN, Saint Raphael Campus ED, uses a handheld scanner to scan a patient's wristband before collecting a specimen. After verbally verifying the patient's ID with her, Pannella will print labels for each specimen from the printer on the WOW, scan the barcode on each specimen and scan the patient's ID band a second time.

When it comes to patient identification errors, a few feet can make a big difference.

That's why the emergency departments are using Soft ID, technology that allows staff to print labels and label specimens right at a patient's bedside, instead of at the nurses' station.

The devices were piloted in the Saint Raphael Campus ED and have been successfully implemented in the York Street adult and pediatric EDs and at Shoreline Medical Center. They will soon be rolled out to other units as part of hospital-wide efforts to improve patient identification and reduce errors that might lead to harm.

Reducing ID errors is a significant effort, led by a patient identification charter team comprising physicians and staff from throughout YNHH. To zero in on particular areas of concern, the team uses the adverse event reports staff and physicians submit, including those made through the "Report a Safety Event" tool available on the intranet. The team has also conducted detailed analyses to determine how certain types of errors are occurring.

Based on these reports and analyses, the charter team is currently focusing its efforts on reducing by at least 50 percent identification errors related to specimen labeling, diagnostic testing, patient registration/arrival and electrocardiogram (EKG) procedures.

"We're not looking at individuals, but at the systems, processes and practices that might be leading to errors," said Allison Clark, RN, patient service manager, General Cardiac unit (Verdi 3 East), and charter team co-chair. "Once we find the causes, we can work with physicians and staff in particular areas to develop solutions to help prevent future errors."

Before implementation of Soft ID in the SRC ED, physicians ordered blood specimens and the labels were printed at a communal printer at the nurses' station. Staff then brought the labels to the bedside and used them for patient identification when obtaining specimens. Although staff diligently followed this strict process for specimen labeling, Soft ID is an improvement because it has increased awareness of the importance of keeping the procedure close to the bedside, said Martha Smith, RN, service line educator.

"With Soft ID, we're collecting and labeling specimens as close to the patient as possible," said Lisa Pannella, RN. "It's the safest practice, and we know we have the right patient, the right specimens and the right labels."

While some identification errors like specimen labeling are particular to specific processes, the patient identification charter team has pinpointed common causes of ID errors that can occur at any time and in any area. These include scanning incorrect patient information into Epic; handing off patients without ID bands; printing ID bands and leaving them on WOWs; and leaving multiple patient charts open in Epic. The charter team is working to raise awareness about these concerns to help people change their behaviors.

The team's work is ongoing but has already yielded positive changes, including the bedside labeling technology, greater staff awareness, increased reporting and tracking of errors, a process for correcting ID errors with the Health Information Management Patient Identity Team and an updated Patient Identification Policy.

Staff are also involving patients more in the identification process, educating them on what to expect and using high reliability organization (HRO) safety behaviors such as read backs and repeat backs. HRO patient safety coaches will work with staff to reinforce the use of this and other CHAMP safety behaviors to prevent patient identification errors. Other behaviors that can be particularly effective include STAR (stop, think, act, review), and mentoring each other and using 200% accountability.

"Our main goal is to change the culture around patient identification," said Diane Collins, RN, Heart and Vascular Center performance manager and charter team co-chair. "Patient identification is so critical to patient safety, we want to make ID errors ‘never events' — the kind of error that should never happen to a patient."