As part of an annual performance improvement review in 2007, Leisa Butler, RHIA, CPHQ, performance manager in the quality management services department at Self Regional Healthcare (SRH) in Greenwood, SC, began tracking safety events occurring within the facility with an identification (ID) events team, consisting of staff members from the operating room, emergency care center (ECC), laboratory, and risk management department.
From this performance improvement review, Butler and her team discovered that patient ID events comprised the majority of safety events occurring at SRH. In targeting patient ID processes, SRH managed to reduce ID events by 65% after one month of implementing a new plan. These ID events included misidentification of a patient, specimen, medication, test results, and medical record.
"We conducted a common cause analysis, and after looking at why the events occurred and the circumstances under which they occurred, we found that the vast majority of patient identification errors were in specimen IDs," says Butler. "The specimens were either mislabeled or not labeled at all." The specimen ID errors occurred on everything from blood to urine to tissue samples.
Bar codes give edge and help with efficiency
Once the aforementioned problems were addressed, Butler and her team focused on preventing patient ID errors. Part of the solution came to Butler via ADMIN RX, an electronic device that scans the bar code on patient ID bands, then scans the medication and confirms the appropriateness of that medication based on pharmacy profiling.
This system essentially helps the nurse confirm that the correct patient is receiving the correct medication.
"We thought to ourselves, 'Why can't we use the scanners on ADMIN RX and give every patient an ID band with a bar code that confirms all the information and is usable for other scanner programs?' " says Butler.
Butler and her team developed a plan that would allow SRH to distribute bar codes to all patients, as well as provide a label for specimens being sent to different areas of the hospital. The team reviewed the cost of supplying the entire facility with bedside scanners and the kind of printer needed to print a scannable armband.
"Printers that would print labels for the ID armband were found. Scanners were purchased that would scan a patient's ID band and generate a label with unique patient identifiers that could be placed on the specimen at the point of collection," says Butler.