This member-only article appears in the August issue of Patient Safety Monitor Journal.
Every time patients are misidentified, they are put at risk. Sometimes the harm is minor: an unnecessary test or being placed in the wrong room. And sometimes the consequences are dire: getting the wrong medicine or having the wrong operation performed. There are numerous points where a mix-up can happen, including at the front desk, during a room change, or during a poorly executed patient handoff.
Austin F. Mount-Campbell, PhD, is a patient safety fellow at the Center for Medical Product End-user Testing in the VA Pittsburgh Healthcare System. He’s done previous studies on the efficacy of patient ID wristbands and patient handoffs.
Q: Why do facilities still struggle with patient ID mix-ups? It seems like it ought to be easy to solve.
Mount-Campbell: It is a combination of issues, even to the point where different facilities have a different set of issues. Generally speaking, it’s related to facilities’ health information technology—either in their own poor design or in the poor integration into the technology ecosystem.
Many facilities also have issues with who is responsible for patient ID. Is it the person who checks in the patient? Is it the unit clerk? Is it the patient’s nurse?
Often, facilities don’t have consistent rules. Sometimes one unit does it one way and you walk down the hall to another unit and things are done differently.
Beyond that, HIPAA and patient privacy teams aiming to protect patient privacy often create unnecessary rules and restrictions that may hinder what might be commonsense solutions.
Q: Please tell me about your research on patient ID wristbands. What were the takeaways on the practice and how to improve it?
Mount-Campbell: My research was related to the accuracy of information on wristbands, why inaccuracies exist, and how we might make them more accurate.
I found as many as half of patient wristbands had misinformation on them, [but] I don’t want you to mistake misinformation as necessarily being dangerous or a patient safety risk; rarely would I consider that dangerous.
My major takeaways are on three levels.
First, each facility should clearly identify who is responsible for patient wristbands in order to establish consistency and ownership.
Second, facilities need to remove information from wristbands that changes frequently (e.g., fall risk, which can change multiple times within a single day, meaning the wristband has to change and you’re adding an extra opportunity to introduce errors). This also creates overload or saturation with respect to the wristband. It’s similar to how too many alarms cause issues—less is more.
Third, we have such wonderful technology that we simply don’t use to our advantage: Wristbands are often generated through computer programs that do not link or communicate with the EHR and function in a silo.