Related Experiment Video
Updated: May 22, 2026
Implementation of Non-invasive Point of Care Transient Elastography for Evaluation of Liver Disease in Pediatric Populations with Cystic Fibrosis
Published on: August 29, 2025
Reduction in pediatric identification band errors: a quality collaborative
Shannon Connor Phillips1, Michele Saysana, Sarah Worley
1Cleveland Clinic Children’s Hospital, Cleveland, Ohio 44195, USA. phillis@ccf.org
Insights
Patient identification band errors were significantly reduced by 77% across six children's hospitals. This collaborative quality improvement initiative demonstrates scalable safety interventions for pediatric patient identification.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety
- Pediatric Healthcare
Background:
- Accurate patient identification is crucial for preventing medical errors.
- Previous interventions to improve patient ID bands have lacked scalability.
- Multicenter collaboratives are needed to disseminate successful safety strategies.
Purpose of the Study:
- To reduce the pediatric patient identification (ID) band error rate by 50% within one year.
- To assess the scalability of a previously successful single-site intervention in a multicenter setting.
- To improve patient safety through enhanced identification practices in pediatric hospitals.
Main Methods:
- A 6-site collaborative was formed, building upon a successful single-site intervention.
- The collaborative involved preparatory work, employee surveys, and data collection on ID band failure rates.
- Interventions were data-driven and focused on collaborative learning to accelerate change.
Main Results:
- The patient identification band failure rate decreased from 17% to 4.1%, a 77% relative reduction.
- Over 11,000 patients were audited across six pediatric institutions.
- Key interventions included staff education, softer ID band materials, and family/patient engagement.
Conclusions:
- A collaborative quality improvement effort significantly reduced patient identification band errors in pediatric institutions.
- This initiative demonstrates that safety improvements can be successfully disseminated across multiple sites.
- The findings support the scalability of tested interventions for improving pediatric patient safety.
Background And Objective:
Accurate and consistent placement of a patient identification (ID) band is used in health care to reduce errors associated with patient misidentification. Multiple safety organizations have devoted time and energy to improving patient ID, but no multicenter improvement collaboratives have shown scalability of previously successful interventions. We hoped to reduce by half the pediatric patient ID band error rate, defined as absent, illegible, or inaccurate ID band, across a quality improvement learning collaborative of hospitals in 1 year.
Methods:
On the basis of a previously successful single-site intervention, we conducted a self-selected 6-site collaborative to reduce ID band errors in heterogeneous pediatric hospital settings. The collaborative had 3 phases: preparatory work and employee survey of current practice and barriers, data collection (ID band failure rate), and intervention driven by data and collaborative learning to accelerate change.
Results:
The collaborative audited 11377 patients for ID band errors between September 2009 and September 2010. The ID band failure rate decreased from 17% to 4.1% (77% relative reduction). Interventions including education of frontline staff regarding correct ID bands as a safety strategy; a change to softer ID bands, including "luggage tag" type ID bands for some patients; and partnering with families and patients through education were applied at all institutions.
Conclusions:
Over 13 months, a collaborative of pediatric institutions significantly reduced the ID band failure rate. This quality improvement learning collaborative demonstrates that safety improvements tested in a single institution can be disseminated to improve quality of care across large populations of children.
Related Concept Videos
01:24Automated Microbial Diagnostics
01:25Errors occurring during blood pressure monitoring
Several factors...
01:23Methods of Documentation V: CBE
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
01:15Methods of Documentation VI: Case Management Model
For example, a patient with a chronic illness...