Dear Colleagues,
Last month Patient Safety Link began its series of theme issues regarding the World
Alliance for Patient Safety’s nine Patient Safety Solutions (read more here), which address what the
Alliance and the Joint Commission International Center for Patient Safety (ICPS) consider
some of the most important global health care safety challenges today.
July’s featured Patient Safety Solution, “Patient Identification” (read the entire
solution here), and its directive to health care workers to make certain of a patient’s
true identity at all times, seems like a simple enough directive on the surface. However, as
pointed out in the Solution, “between November 2003 and July 2005, the United Kingdom
National Patient Safety Agency reported 236 incidents and near misses related to missing
wristbands or wristbands with incorrect information.(1) Patient misidentification was cited
in more than 100 individual root cause analyses by the United States Department of Veterans
Affairs (VA) National Center for Patient Safety from January 2000 to March 2003.”(2) What
appears to be a simple procedure is not so simple after all.
In our first article, “Helping Hippocrates: A Cross-Functional Approach to Patient
Identification,” the efforts of one organization—St. Francis Hospital in Poughkeepsie,
New York—to improve its patient identification procedure are detailed. After members of all
hospital departments were assigned a specific day on which they would compare the patient’s
identification band with the patient census report, patient identification errors declined
from 8.2% to a sustained zero.
“Labeling in the Laboratory: Using Two Patient Identifiers in the Presence of the
Patient,” our second article, gives five recommendations to laboratory staff (and other
departments working with the lab) for making certain of a patient’s identity, both in the lab
and at other points of the patient’s organizational “journey.”
“Patient Identification Accuracy” gives practical, concise direction on
patient-identifier compliance as directed by The Joint Commission’s National Patient Safety
Goal 1. A customizable email message for staff is also included.
Finally, we introduce you to the ICPS’s two Project Directors, Laura Caisley and
Gerard Castro. Both are integral to the Center’s daily operations and success, and we
are happy to share some information about the wealth of health care experience Laura and
Gerry bring to our cause.
Does your organization have recent positive experiences with Patient Identification
that you would like to share? Let us know about your success! Send an email by selecting this
link: http://www.jcipatientsafety.org/24725/.
References
- Wristbands for hospital inpatients improves safety. National Patient Safety Agency, Safer
practice notice
11, 22 November 2005. http://www.npsa.nhs.uk/site/media/documents/1440_Safer_Patient_
Identification_SPN.pdf
- Mannos D. NCPS patient misidentification study: a summary of root cause analyses. VA NCPS
Topics in Patient Safety. Washington, DC, United States Department of Veterans Affairs,
June–July 2003 (http://www.va.gov/ncps/TIPS/Docs/TIPS_
Jul03.doc, accessed 11 June 2006).
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Peter B. Angood, M.D., FRCS(C), FACS, FCCM
Vice President & Chief Patient Safety Officer, The Joint Commission
Co-Director,
Joint Commission International Center for Patient Safety | Laura
Botwinick
Co-Director
Vice President, Joint Commission Resources
Joint
Commission International Center for Patient Safety |