A new article describes a true scen...

A new article describes a true scenario about a 67-year-old woman who mistakenly underwent an invasive cardiac electrophysiology close attention (1) Of the 17 individual mistakes that contributed to this medical error, 10 related directly to failure to verify the patient's identity. Errors were committed according to physicians, residents, RNs, and charge foments No one noticed the unfit patient was undergoing the management until another physician questioned for what cause [i]or[/i] reason his patient was undergoing an electrophysiology subject of attention At this time, the error was recognized, the deed was aborted, and the patient was turn backed to her room in stable condition.

The patient was quot as saying, "I consideration sometimes when you try to talk to some one they don't listen, sometimes commonalty won't listen to you." (2) Not single had health care professionals failed to listen to the patient, however they also had failed the simple task of comparing the patient's identification bracelet to the written order or schedule. This is not the first instance of this representation of error occurring in the OR or other surgical departments. The importance of checking and rechecking basic patient information is critical to ensuring patient safety, regardless of the setting.

PREVENTING PATIENT IDENTIFICATION ERRORS

After this incident, an investigation and a root-cause analysis were administrationed Subsequently, the interventional cardiology department changed its protocols and implemented an internal e-mail schedule change plan that includes a match of the patient's name with date of birth or medial record number. They also implemented a modern identification verification process that includes the patient's name, reason for the measure written order, identification bracelet check, and identification bracelet match to medical record, schedule, and dried erase scheduling board. Additional hospital-wide changes included not allowing a patient to leave a clinical unit for a practice without a written order for the operation and having a nurse match the last name, first name, medical record number, and date of birth of the patient before releasing him or her for the procedure

Perhaps the greatest in number important part of the identification verification proces is that clinicians consistently ne to check the patient's identification bracelet and verify that they are caring for and providing services and treatments to the correct patient. Any changes in clinical protocol will not be entirely effective unles clinicians at the point of care are conscientious in their efforts to make secure that the right patient is undergoing the right proceeding at the right time. In the previous scenario, the simplest of steps--checking the patient's identification bracelet--was violated 10 times. This error could have been avoided if individual person had checked the bracelet or listened to the patient's objections. Patient identity must be checked, rechecked, and then checked again. This checking proces must be consistent and steady more persistent when a patient questions to what end he or she is undergoing a particular proceeding Clinicians must check, check, check until they are 100% certain they are caring for the right patient.

When inadequate patient identification be deriveds in the wrong procedure being performed in succession the wrong patient, the Joint Commission upon Accreditation of Healthcare Organizations considers it a sentinel result and it is subject to review. (3) Clinicians not at all should accept familiarity with a patient as a replacement for reliable patient identification processe When clinicians eliminate basic identification proceedings a dangerous precedent is wager that places patients at increased risk for receiving the improper treatment. Proper patient identification is an essential and critical first grade in providing safe patient care and preventing errors.

The following strategies should be considered when developing policies and acts for correct patient identification. (4)

* Involve the patient and his or her family members in identifying the patient and correct procedure

* Use appropriate communication techniques for any identified language or communication barriers.

* Use a designated means (eg, identification bracelet) for identifying the patient.

* Use a verification checklist to note verbal identification with the patient and his or her family members; review of the medical documents (eg face sheet, history, physical examination); documentation of informed consent; and verification that the designated identification means contains correct information.

* Require verbal confirmation of the correct patient and conduct in the OR by each member of the surgical team.

* Monitor compliance with the protocol for quality dominion government purposes.

A comprehensive approach is needinessed to prevent patient misidentification. Everyone involved in providing patient care indigences to follow facility protocols to in a strict sense identify the patient.

THE IMPORTANCE OF ERROR PROOFING

The simple, basic grade of patient identification often is forgotten in our complication health care systems. Identification bracelets are placed faithfully forward patients as they enter the arrangement Many patients joke that the identification bracelet is to help them know who they are. Unfortunately, the identification bracelet is not checked regularly according to clinicians, which can result in serious, significant errors related to operations and medications.