Identifying patients accurately at...

Identifying patients accurately at hands many unique challenges in today's health care settings. First and foremost, error-proof classifications have not been developed or implemented. Facilities have bring outed setting-specific solutions, but wide adoption of a single failsafe approach or solution has not occurr The fast-paced nature of clinical settings may contribute to the difficulty clinicians and others experience in their efforts to correctly identify patients when providing care.

business for proper patient identification is evidenced in the 2003 National Patient Safety Goals. (1) united of the six identified goals is to improve the accuracy of patient identification. The related recommendations state that at least couple patient identifiers, not including the patient's latitude number, should be used when relations samples are obtained or medications or family are administered. The second recommendation relates to conducting a final verification during which active communication is used to confirm identity before the start of a manner of proceeding (1)

NEAR MISSES AND ADVERSE EVENTS

The Joint Commission in succession the Accreditation of Healthcare Organizations (JCAHO) has issued several sentinel incident reports that describe errors in patient identification. Classified as single in kind type of wrong-site surgery incorrect patient identification has eventuateed in a patient undergoing an unnecessary proceeding or surgery. In fact, a new Sentinel Event Alert reported that, at that time, 13% of wrong-site surgeries involved surgery in succession the wrong patient. (2)

united such error was reported in an article titled "The unfair patient," in which the authors described a series of errors that led to health care personnel missing numerous opportunities to correctly identify a patient. (3) These errors deductioned in the wrong patient--a 67-year-old woman--undergoing an invasive cardiac deed This adverse event was linked to absent or missed patient identification protocols and lack of informed consent

in the greatest degree fundamental nursing textbooks and courses describe the importance of verifying a patient's identity. This basic ritual and routine is integral to the medication administration proces treatments, and transactions Student nurses learn to check a patient's identity during the intra-operative phases of care, of the like kind as when the patient is transferred to the holding area, OR, or postanesthesia care unit.

Despite this education, mostly nurses can describe a near-miss incident or actual adverse incident in which a patient received a medication intended for another patient. An example of a near miss includes an marked occurrence in which a patient was placed in the inapposite OR suite or transferred to the OR without a name bracelet. Patients bear tests, procedures, or surgery each day in health care facilities without anyone checking their name bracelet.

to what end do these errors occur? No common is entirely certain. The Joint Commission reports that in the past seven years,

* communication,

* orientation and training,

* patient assessment, and

* availability of information were the four chiefly common root causes for wrong-site surgery and all originals of sentinel events. (4) These causes move the need for fail-safe plans that are highly reliable and error proof

Despite multiple changes in the health care plan during the past 30 years, principally facilities continue to use a patient identification proces and combination of parts to form a whole that was developed at least three decades ago. Certainly no united providing care intends to incorrectly identify a patient. The regularitys clinicians use, however, create opportunities for error. For example, it is not unwonted to remove a patient's identification bracelet to insert an IV line or because the arm will be subordinate to the patient during the action In the OR, patients' arms frequently are covered so the name bracelet is not easily accessible. During the transaction the nurse may be relieved for a break, to such a degree the patient's identity cannot be verified easily other than according to reviewing his or her chart.

In an effort to address identity issues in the OR, JCAHO has attract favor toed a time-out before the start of surgery The design of this time-out includes checking the prototype of procedure, surgical site and laterality, and patient identity. Despite these recommendations, errors and near misses continue to occur

In fact, reports of near misses to AORN's Safety trap describe events in which promotes have observed or have been involved in patient identification moot points These issues include events in which multiple providers admitted they had not checked a patient's name band because they were in a urge [i]or[/i] press on Nurses report having served a explanation role in the checks and balances proces to identify patients. It is clear from the case reports related to identity that the causes of errors are multi-factorial and reside in intricate systems.

CLINICAL RECOMMENDATIONS

All clinicians ne to be touched with the processes and schemes that support correct identification of patients. An approach to ensuring a best practice for patient identification includes implementing a clearly written, easy-to-understand policy and operation To be fully implemented, the policy and course must be supported by available resources. For example, name bands will be remov for a variety of reasons; therefore, it is critical to have an adequate number of replacement bands and a easy proces for a strange bracelet to be stamped and applied.