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An intervention to decrease patient identification band errors in a children's hospital

Paul D Hain1, B Joers, M Rush

  • 1Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee 37232-9750, USA. paul.hain@vanderbilt.edu

Quality & Safety in Health Care
|April 6, 2010
PubMed

Insights

Reducing patient identification band errors is crucial for safety. Interventions significantly decreased defect rates from 6.5% to 2.6% through staff engagement and clear protocols.

Area of Science:

  • Healthcare Quality Improvement
  • Patient Safety Initiatives
  • Hospital Operations Management

Background:

  • Patient misidentification remains a significant healthcare quality and safety concern.
  • Limited US data exists on effective interventions to reduce identification band error rates.

Purpose of the Study:

  • To describe interventions implemented at a children's hospital to reduce patient identification band errors.
  • To evaluate the effectiveness of these interventions on reducing defect rates.

Main Methods:

  • Utilized web-based surveys to identify perceived barriers to zero defects in identification bands.
  • Developed and implemented corrective action plans based on leadership, staff input, and survey data.
  • Conducted unannounced audits, plotted data on statistical process control charts, and educated staff on a 'stop the line' protocol.

Main Results:

  • Initial audit revealed a patient identification band defect rate of 20.4%, with a baseline mean of 6.5%.
  • Post-intervention, the mean defect rate significantly decreased to 2.6%.
  • Staff awareness and empowerment to 'stop the line' were identified as key drivers of improvement.

Conclusions:

  • The hospital initially experienced a higher-than-expected rate of patient identification band errors.
  • Staff engagement, clear expectations ('stop the line'), and utilizing staff feedback via surveys were critical for success.
  • Continuous auditing and data sharing using statistical process control charts are essential for sustained improvement in patient identification accuracy.
Abstract

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