Module 1 : Improved Hand Hygiene to Prevent Health Care-Associated Infections
Module 2 : Patient Identification
Module 3 : Communication During Patient Handovers
Module 4 : Medication Safety Basics
Module 5 : Additional Topics in Medication Safety
Module 6 : Assuring Medication Accuracy at Transitions in Care
Module 7 : Fall Prevention
Module 8 : Pressure Ulcer Prevention
Module 9 : Psychological Wellbeing
Module 10 : Safe Procedures
Module 11 : Patient Rights
by Adriana Arcia, Johis Ortega, & Susana Barroso
School of Nursing and Health Studies, University of Miami
In this module, you will learn how to perform safe identification of patients and how to prevent errors related to incorrect patient identification. Let’s get started!
Errors in patient identification are the root cause of a wide variety of incidents that compromise patient safety. For instance, misidentification can “result in medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families.” Given the potential serious consequences of errors in patient identification, it is essential for all nurses to implement effective techniques for correct patient identification.
|Objectives for Module 2
Upon completion of this module, you should be able to:
Consider a healthcare facility, perhaps one in which you work or have worked. Recall an incident in which a patient identification error occurred. What were the circumstances that led to the error? What were the consequences of that error for the patient(s) involved? What actions were taken by the healthcare facility following the error?
Before you can provide nursing care, you must first ensure that you are working with the correct patient. Even the most expert nursing care can cause harm if it is directed to the wrong patient. Take the time to identify your patient correctly. Remember also to identify yourself to the patient! Read this patient safety solution to learn the best way to prevent patient identification errors:
• It is your responsibility to match the correct patient with the correct care before the care is administered.
• Use at least 2 identifiers, such as name and date of birth or medical record number, before providing care. Do not use the patient’s room or bed number to identify them.
• Checking the patient’s identification bracelet can aid in the identification process in settings where these are used.
• Consult your workplace policies for distinguishing patients with the same name.
• Encourage patients and family members to be active participants in the identification process.
• Label specimens (such as blood or urine) in the presence of the patient.
• Question a lab result and test finding if they are not consistent with your patient’s clinical history.
Adapted from: World Health Organization. (2007). Patient Safety Solutions-Patient Identification. Aide Memoire, Volume 1 (Solution 2). Retrieved fromhttp://www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf
It is not uncommon to have two patients with the same or similar names on a unit. Using a second identifier, such as date of birth, is an easy way to prevent identification errors from occurring. If possible, patients with similar names should be placed on different units. Place a “name alert” label on the chart of every patient whose name is similar to others’. Therefore, if three patients have similar names, all three charts should have a name alert label so that all staff know to take special care with patient identification.
Keep in mind that patients can be dealing with conditions that impair their ability to identify themselves, such as dementia or the side effects of medications. Therefore, DO NOT ask a patient, “Are you Maria Hernandez?” She may say yes, even if she isn’t. Instead, get into the habit of asking the patient to tell you his or her name and date of birth (or other 2nd identifier). If your patient is not able to communicate effectively with you, use an alternative method to verify his or her identity, such as checking the patient’s identification bracelet or enlisting the help of visiting family and friends.
Even the best nurses can get so busy that an error can occur. Get into the habit of labeling patient specimens in the presence of the patient to prevent mix-ups, missing specimens, and mislabeling. Take a few moments to do this to save yourself and your patient from bigger headaches later on.
Errors still can occur even if everyone is working hard to prevent them. Sometimes a lab or test result won’t seem right to you, such as an x-ray showing a fractured left femur on a patient who came in complaining of pain in the right ankle. Question the result until you are satisfied that the result has been matched to the correct patient.
Case Study 2
Mr. and Mrs. Mendez were brought to the emergency department by ambulance after they were involved in a motor vehicle accident. They were placed in neighboring beds and assessed. Mr. Mendez had sustained bilateral femur fractures but was hemodynamically stable. Mrs. Mendez had low blood pressure that did not respond to treatment with wide open crystalloids and the on-duty physician suspected internal bleeding. Both patients had blood drawn to be typed and crossed. The nurse labeled the specimens at the nurses’ station and sent them to the blood bank along with the order for packed red blood cells (PRBCs) for Mrs. Mendez.
When the PRBCs arrived at the emergency department, Mrs. Mendez’s nurse called for help from another nurse to complete the two-person verification process. They matched the PRBCs to the order and to Mrs. Mendez’s ID band, confirming name and birth date. When Mrs. Mendez overheard the nurses say that the PRBCs were type B+, she insisted that the blood could not be for her. She explained that she wasn’t sure of her blood type but that she knew it was “something negative” because she had to have “a special shot” (RhoGam) after her son was born. The samples that were sent to be typed and crossed had been mislabeled and the nurses were about to administer a blood product that was a match for Mr. Mendez. Mrs. Mendez could have suffered a serious reaction if she had not advocated for herself.
Case study adapted from Agency for Healthcare Research and Quality. (2004, February). Transfusion “Slip.” Morbidity & Mortality Rounds on the Web, retrieved from http://www.webmm.ahrq.gov/case.aspx?caseID=50
Case Study Questions
Which of the nurse’s actions caused the identification error? What technique have you learned that would have prevented the error?
What role did patient education take in this case?
Integrating Your New Knowledge
Reflect again on the thinking question from the beginning of this module. Incorporating what you have learned, analyze the relevance of the actions taken by the healthcare facility.