Avoiding a Medical Disaster

A nurse sees an elderly patient being pushed on a stretcher down the hall. Although she is not assigned to you, you heard change of shift report and wonder why the Operating Room orderly is there. You stop the orderly at the foot of the stretcher and ask, “Where is she going?” The orderly says, “I was told to take the patient in 562 B to the operating room.” You ask, “Did you check her name band and ask for her birthdate?” “No, I just headed to her bed.” In this true situation, the nurse’s quick action stopped the wrong patient from being taken to the operating room for an unplanned surgery.

You are sitting in a waiting room, like I was recently, while my spouse has a colonoscopy. I watched the same day surgery nurse scan the room and call, “Barbara?” A woman gets up from her seat and enters the same day surgery holding area. Within 60 seconds I watched her being escorted out by the nurse. I heard the nurse say, as she walked the patient out of the unit, “The orthopaedic waiting room is next door.” Checking patient identifiers prevented this woman from having an unnecessary procedure.

Patient identifiers

Not accurately identifying the patient may lead to mistakes in medication administration, surgeries, treatments, discharges, lab tests and a variety of other potentially harmful outcomes. The fast moving pace of health care can result in pressure (called production pressure) to quickly move through care, but may lead to dangerous shortcuts. Using at least two patient identifiers reduces the risk. These are examples of what staff should do to check patient identifiers:

• Ask the patient to state her name
• Ask the patient to give her date of birth
• Check a name band
• Verify the name band number with the medical record number
• Take and refer to photographs of the patient’s face
• Look at a driver’s license with a photograph

Blood transfusions

“Could you do a favor for me? Could you hang this unit of blood on my patient while I head to lunch?” The two nurses stood at the nursing station looking at the unit of packed red blood cells. They verified that the unit of blood matched the identification number on the patient’s chart. “What room is your patient in?” Given the wrong room number, the nurse walked into the wrong room, did not check the patient’s identification band, and hung the blood. In this true situation, he received blood which was incompatible with his own and died.

Staff should never use the room number as a patient identifier. Blood verifications should be done by two people at the patient’s bedside, with one of the nurses being the one caring for the patient.

Labeling specimens

Using identifiers also applies to lab specimens. It is all too easy to mix up unlabeled tubes of blood. All specimens should be labeled in the presence of the patient to minimize the risk of mixing it up with another person’s specimens. The facility should be sure the protocols are clear and that all new employees receive orientation and continuing education on the importance of correct patient identification.

Correctly identifying a patient using patient identifiers before acting should be a 100% of the time activity. The fact that the wrong patient ends up receiving medicaitons, blood or surgery means that we are not there yet.

Med League nurses have expertise in analyzing medical records for inconsistencies and abnormalities. Contact us for a deep medical analysis of your case.