SDS Accreditation Update

Special Report: Patient ID errors

This month's SDS Accreditation Update includes a focus on the perennial and potentially disastrous problem of patient identification errors.

Despite an intense focus on proper specimen labeling and other strategies for reducing identification errors, these problems still occur. Our special report provides tips and the latest advice for how to reduce identification errors in your own healthcare organization.

Specimen labeling still a major risk for ID errors, can lead to huge liability

Technology, focus on human factors can help

Patient identification errors continue to plague the healthcare industry despite years of efforts to eradicate this potentially disastrous problem. Understanding why patients and specimens are misidentified is key to reducing or eliminating errors, and managers can make progress by focusing on the human behavioral components.

Specimen labeling is one of the biggest risks for misidentification, with errors leading to delayed or wrong diagnoses, missed or incorrect treatments, blood transfusion errors, and additional laboratory testing. Literature reviews have identified specimen labeling error rates of 0.1% to 6.5%.

Recognizing this risk, The Joint Commission has implemented two National Patient Safety Goals (NPSGs) for 2011 related to patient identification for hospital and ambulatory organizations, as well as office-based surgeons:

  • NPSG.01.01.01 is "Use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment."
  • NPSG.01.03.01 is "Make sure that the correct patient gets the correct blood when they get a blood transfusion."

The College of American Pathologists also includes patient and sample identification as one of its five top patient safety goals. (For information on efforts by the Accreditation Association for Ambulatory Health Care, see story, below.)

Phlebotomy is one of the fields most focused on labeling errors, and many healthcare providers take a punitive approach to errors, says Fran Charney, RN, MSHA, CPHRM, CPHQ, CPSO, FASHRM, director of educational programs with the Pennsylvania Patient Safety Authority (PPSA) in Harrisburg, PA. Before joining the PPSA, Charney was a healthcare risk manager and patient safety officer.

"Many organizations talk about taking a systems approach, but when it comes to phlebotomy, they have a 'three strikes and you're out' approach," Charney says. "Then we ask if the problem went away when they fired that phlebotomist, and of course they say it didn't." (The PPSA recently sponsored a multi-hospital blood specimen labeling collaborative that resulted in a 37% decrease in labeling errors. For more on that effort, see the story, below.)

Charney encourages managers to look at specimen labeling errors as a system problem, treating them much like any adverse event and asking not just who made the error, but why that error was possible and how it could be prevented. "A lot of times we don't dig deep enough to see why the error occurred," she says. "We just say Sally the phlebotomist made a mistake and put that in her record. If she forgot to double check the ID because the phone was ringing off the hook, why was that? Because you were short staffed?"

Understanding human factors is a big part of reducing identification errors, says Megan Shetterly, RN, MS, patient safety liaison for the Northeast Region of the PPSA. When investigating an error, ask not only what happened and how, but why, she says. "We need to ask them why several times, to drill down and find out what led to this error, not the simple mechanics of how it happened," Shetterly says. "The nurse or phlebotomist might say she grabbed the wrong label, but you can't leave it at that. Why did she take the wrong label? What was going on, and what about your procedures made it possible for her to do that?"

Common causes are disruptions, interruptions, and increased work load, Shetterly says. The most often cited explanation is that the employee was not following procedures, but the next question must be why, she says. The answer also involves the workload. "They often say that to get the workload done, they don't have time to do the A, B, C, and D that are spelled out in the policies and procedures," Charney says. "So they decide C isn't really necessary, and they do a workaround. That sounds like an individual decision, but we put them in an unsafe place where that looks like the only way out."

Patients should be involved with confirming their identification as much as possible, Charney says. Too often, she says, the caregiver enters the room and asks "Are you Mr. John Smith?" or says "You're Mr. Smith, right?" and the patient nods or mumbles a response. That interaction is not acceptable, Charney says. "A much better way is to say, 'Can you state your name for me?'" she says. "That is a very different question, and you get a much better response. Sometimes you can go on and ask the patient to spell the last name. That kind of active participation by the patient is crucial."

Bar coding technology can significantly reduce patient identification errors, but it is not a panacea, Shetterly says. She notes that the Centers for Disease Control and Prevention has recognized bar coding as a best practice for specimen collection. (See the story, below, for more on bar coding.)

"The technology is very good, but it's only as good as the person using it," Shetterly says. "You still have the human element, so errors can occur. (See story on liability, and for more solutions for reducing errors, below.)

AAAHC lists patient ID standards

The Accreditation Association for Ambulatory Health Care (AAAHC) requires accredited organizations to avoid patient identification errors by having unique patient identifiers, according to Michon Villanueva, assistant director of accreditation services.

These standards include:

  • Chapter 6, Clinical records and health information, standard B-1: An individual clinical record is established for each person receiving care. Each record includes, but is not limited to: an identification number (if appropriate).
  • Chapter 6, Clinical records and health information, standard F-3: A designated person is in charge of clinical records. This person's responsibilities include, but are not limited to: the unique identification of each patient's record.
  • Chapter 7, Infection Prevention and Control and Safety, Subchapter II, Safety, standard: Unique patient identifiers are consistently used throughout care.

In addition, an organization that provides surgical and related services is required to have a process to verify a patient's identification prior to performing the procedure:

  • Chapter 10, Surgical and Related Services, Subchapter I, General requirements, standard V: Immediately prior to beginning a procedure, the operating team verifies the patient's identification, intended procedure, and correct surgical site, and that all equipment routinely necessary for performing the scheduled procedure, along with any implantable devices to be used, are immediately available in the operating/procedure room. The provider performing the procedure is personally responsible for ensuring that all aspects of this verification have been satisfactorily completed immediately prior to beginning the procedure.

Are you at risk for being sued?

Mislabeled specimens are liability

The malpractice implications of a mislabeled specimen are significant, says Laura A. Dixon, JD, RN, CPHRM, director of the Department of Patient Safety for the Western Region of The Doctors Co., a malpractice insurer in Napa, CA.

A patient might receive care indicated for someone else, while the other patient does not receive needed treatment. "Some of these errors can have long-term lasting physical effects on the patient," Dixon says. "But in addition to the physical problems, the individual also may the emotional trauma. Of the claims we have from identification errors, the majority are about emotional trauma rather than physical injury."

The typical lawsuit involves a relatively young and healthy individual who underwent an unnecessary procedure and believed for some period that he had cancer or another serious illness, Dixon says. The potential liability will depend on how state law addresses claims of emotional distress, but the payout tends not to be in the millions of dollars, she says.

Delayed diagnosis is a bigger liability risk, Dixon says. A delayed diagnosis of cancer because of a specimen mixup, for instance, could result in a costly malpractice lawsuit, she says. "Those cases tend to involve real injury and perhaps an impact on long term survivability, so they can be quite costly, both in terms of the payout and the cost to defend them," Dixon says.

PA hospitals cut label errors by 37%

A project designed to analyze labeling errors and devise solutions resulted in a 37% decrease in errors across nine hospitals in Pennsylvania.

From August 2009 through October 2010, the Pennsylvania Patient Safety Authority (PPSA) sponsored a multi-hospital blood specimen labeling collaborative. The PPSA worked with the hospitals to measure blood specimen labeling error rates, document hospital-specific interventions to reduce the labeling error rate, and measure the outcome of the interventions.

Eight acute care hospitals and one rehabilitation hospital participated in the collaborative, says Megan Shetterly, RN, MS, patient safety liaison for the Northeast Region of the PPSA. Some of the hospitals used bar coding technology in some areas but not throughout the hospital. Each hospital assembled a team to participate in the collaborative, and team members included laboratory directors, phlebotomy supervisors, patient safety officers, and risk management, quality and performance improvement, and regulatory compliance personnel.

PPSA provided educational sessions about reliable design, just culture, and human factors engineering. Subsequently, each hospital team mapped its blood specimen labeling process, assessed the process for compliance through direct observation, and presented an overview of the processes to the rest of the collaborative participants. This project was an opportunity for the collaborative participants to identify barriers to labeling compliance that transcended specific care areas and organizations, Shetterly says. Common barriers were those related to technology, communication, education, staffing, workflow, and leadership.

PPSA also trained participants in root cause investigations, and by October 2010 it had collected and analyzed 485 investigations. Facilities reported 520 contributing factors associated with the mislabeling errors. The top three contributing factors were procedures not followed, distractions and interruptions, and unplanned workload increase.

The collaborative participants implemented more than 20 interventions between April and July 2010. There were six major categories of barriers to blood specimen labeling accuracy: technology, communication, education, staffing, workflow, and leadership. The collaborative participants implemented several interventions within these domains to improve specimen labeling accuracy. Overall, there was a 37% statistically significant decrease in blood specimen labeling errors in the collaborative over the 18 months, Shetterly says.

The PPSA project also involved patients by encouraging them to question caregivers about following proper identification procedures. Patients were given pens as a small gift that might be used and seen often, and signs were posted in rooms with the slogan "Did you ID me?" The program is similar to the national campaign from The Joint Commission, with the Centers for Medicare and Medicaid Services, to urge patients to take a role in preventing errors by becoming active, involved, and informed participants on the healthcare team.

Shetterly also encourages healthcare facilities to shadow staff doing blood draws and other specimen collection. "We followed around some of these nurses who were doing the blood collection, and we saw things that the project managers in the hospital didn't see," Shetterly says. "Sometimes it takes a fresh set of eyes. If you're around the same place long enough, you don't notice that cobweb up in the corner anymore." (The full PPSA article, "Reducing Errors in Blood Specimen Labeling," is available online at

Bedside barcodes reduce pharm errors

Barcoded wristbands can greatly reduce the opportunity for patient identification errors, says David Grant, RPh, MBA, vice president of pharmacy and clinical process improvement at Summit Health in Chambersburg, PA.

The barcoded wrist band is placed on the patient at admission and then is used for all specimen collection and medication administration, Grant says. Summit Health first began using the barcode technology about six years ago, when about 15% of U.S. hospitals were using it, he says. Now that figure is closer to 35%, he says.

Summit's barcode system is used in the pharmacy when the medication is dispensed and also at the bedside before it is administered. "The nurse uses a handheld scanner to read the barcode, and if they have the right patient, they are allowed to proceed with administering the medication," he says. "If they don't have the correct patient, it closes the medication administration record and notifies them that they don't have the right patient."

As a result of the barcode technology, "wrong patient administration errors have all but disappeared," Grant says. That success eliminates about 30% of all medication errors, because administration errors make up about 15%, dispensing errors account for another 15%, and transcription errors result in about half of all medication errors, he says.

Staff members have responded well to the new system, with more experienced nurses saying they would never want to go back to paper medication orders, Grant says. Summit spent about $1 million on the hardware and other infrastructure necessary for the barcode system. Planning took about two years, and the new system was rolled out over eight months.

"It's been a resounding success for us, and we wouldn't go back," he says.