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

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.