A "Step Backward" in Patient Safety?

Joint Commission Changes Requirement for Patient ID during Blood Draws | Dark Daily

Thanks to my friend Robert Michel and the Dark Daily for bringing this story and issue to my attention. Definitely check out his web site if you work in the laboratory and pathology fields.

Keep reading here if you’re interested in patient safety… that should be all of you, I suppose.

When drawing blood (collecting a specimen) from a patient, it’s very important to make sure that there are no errors in matching the patient to the specimen that is sent to the lab. Erroneous laboratory results can delay the proper patient care or lead to incorrect medical decisions being made for a patient.

Laboratories and those who draw blood (nurses or phlebotomists — the specialists who collect blood) take many precautions and need to follow consistent standardized work to prevent errors or specimen mismatches.

For example, to avoid labeling errors, it is important to label specimens (by hand or, better yet, with printed labels and bar codes) IMMEDIATELY after blood is collected. If you batch up the labeling, you introduce the risk of mixing up patient specimens.

It’s also important to confirm the identity of the patient you are drawing, to make sure the labels you are about to put on the tube indeed match the patient.

In the case of patients with the same name, hospitals are supposed to use TWO identifiers (name and date of birth or a unique identifier number). These dual identifiers are often found on the patient’s wristband.

But what if the wristband is on the WRONG patient? Up to 16% of wristbands have erroneous information (link). You might be verifying TWO pieces of equally incorrect information on that wristband. That’s why a “best practice” has been to verbally ask the patient to state their name (of course, not all patients have the capability to do this). I’ve seen phlebotomists do this many many times. It makes sense.

It was shocking to me to see that the Joint Commission has removed the rule requiring this precaution. Phlebotomy and laboratory experts are questioning this change, advising that hospitals continue to follow the higher level of standards still advocated by those groups — continue asking the patients to identify themselves verbally.

When The Joint Commission recently changed the patient identification requirement for drawing a blood sample, one national phlebotomy leader considered it a step backward in patient safety.

“Per a revised policy issued by The Joint Commission, it is no longer required for the phlebotomist or person drawing the blood to actively involve patients by, for example, asking them to state their name,” commented Dennis Ernst, MT(ASCP), the long-serving Director of the Center for Phlebotomy Education. He’s one of the leading observers of phlebotomy trends and he’s concerned about what this means to patient safety.

“Having a patient state their name before a blood collection is a very important step in patient identification,” declared Ernst. “The Joint Commission now finds it acceptable for the phlebotomist to use the identification bracelet alone, which we all know can end up on the wrong patient. That’s disturbing to me because it’s taking a chance with a patient’s life. I think any time you dilute the requirements for patient identification, you create a possible scenario that is not favorable to anyone seeking healthcare.”

Read the Dark Daily piece for more comments. I agree with Ernst. Why would you remove this simple, yet important verification?

The Joint Commission informed him that their clients feel that it is “burdensome and unnecessary” to ask a patient to confirm his or her name.

Burdensome? What?? It takes all of a few seconds. Unnecessary?? Unnecessary if you’re arrogant and think that your organization couldn’t possibly put the wrong wristband on the wrong patient.

The Joint Commission explains:

“…it was determined that the EP was rendered not surveyable or enforceable through the accreditation process. This is the reason behind the deletion. We continue to support active patient involvement in the identification process as a best practice and will encourage organizations to use such an approach when it is reasonable to do so.”

So they are encouraging it, but not requiring it?? The rule was not enforceable, so they removed it? Seems like that sends a mixed message.

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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

11 Comments on "A "Step Backward" in Patient Safety?"

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  1. Anonymous says:

    Are you kidding me? People would want to cut corners and NOT check the patient's identity? It's too burdensome to talk to the patient??

    No wonder healthcare is so f-ed up.

  2. shana says:

    I agree that requiring verbal identification and comparing this information to the medical record is an important step in delivering high quality patient care. I don't agree that JC is responsible for mandating and monitoring this important process.

    In my mind, this discussion relates to some misconceptions about what accreditation, benchmarking and peer review will provide – and more importantly – what it will NOT provide….

    Quality, safety, standardized work, error proofing processes are best developed and delivered at the source of care. There are many practices and procedures in the lab and in healthcare that are above and beyond those minimums required by accrediting agencies.

    These minimum criteria are essential to insure the baseline for quality, for accreditation to have meaning and to compare hospitals to a standard in order to provide meaningful feedback to the organization for areas of improvement. Accredition does not equal the highest quality care – if so we wouldn't have the errors that occur daily in healthcare environments.

    JC commission visits most hospitals every 2 years, spending around a week reviewing, interviewing and assessing. People giving care are there every day – who is better able to monitor and manage a process?

    I would prefer that JC idenitify the areas they cannot impact – "…it was determined that the EP was rendered not surveyable or enforceable through the accreditation process. This is the reason behind the deletion." – rather than rubber stamp the protocol and invite unearned confidence in an organization.

    I applaud all healthcare organizations who are making the real difference by thinking for themselves – using those basic minimums to launch the initiatives that make the most sense in that organization. Healthcare organizations vary tremendously – from the depth and breadth of available technology (i.e. all paper to all electronic), in their struggles due to demographics (multi-lingual, pediatrics or geriatrics), location (rural or metropolitan), patient care type delivered (trauma, surgery, alzheimers, etc). Each one of these unique organizations must take those minimum recommendations and then, with the people who perform the work in that healthcare environment, develop protocols and processes that insure that they will deliver the highest quality care possible.

  3. Mark Welch says:

    Well said, Shana, but don't you think verbal confirmation should be a MINIMUM? I must admit as a person who has been a patient numerous times in hospitals that I'm a little flabbergasted that this would be removed from the protocol. As much as it pains me to say this, it appears as though your viewpoint is one that is using "let the hospitals decide" as a way out of the argument. What other things should we let hospitals decide? Whether or not to change needles between patients for vaccinations?

  4. Lucas says:

    Working with healthcare providers I agree that this is a very important step. However, I have also seen where this might be a waste. How many times do we need to ask the same patient the same questions? We need to put the quality inspection as close to the source as possible. So the arm band identifier is verified when it is applied to the patient.

    We want to drive out the waste of duplication and excess processing.

  5. Mark Welch says:

    Lucas,

    I agree with you in principle, but the wristband is wrong up to 16% of the time. Given this, is it worth risking that it's right? Until the wristband process is error-proofed, I think verbal confirmation is necessary.

  6. shana says:

    Lucas & Mark-

    The wristband has wrong information 16% of the time – NOT the wrong name 16% of the time. Asking for verbal confirmation of the name will not address all of the referenced errors.

    Getting the correct patient specimen in the correctly labeled container is imperative. What do we do for patients that cannot speak, are not lucid, do not speak the phlebotomists' language, and so on? What do we do for specimens collected when the patient is anesthetized, distracted, hurt or scared?

    Even when patient can talk – verbal communication is an error prone process. I still stand by my assertation that I don't want any accrediting body to grant credentials based on information they can't confirm. False confidence is not what I want as a patient.

    What truly robust, meaningful & measurable process can be (or has been) developed for this crucial step in specimen collection??

  7. Mark Jaben says:

    What do the patients think?

    They really hate being asked their name and birthdate 10 times a day. Ask them sometime

    Doing this seems like a workaround to the more fundamental problem of making the identifier work the first time and every time. If this needs to be name badge, then so be it. Let's engage the patients with the reason correct identification is so important right up front for those who are able to be engaged. Let's figure out ways to reliably include the patient as part of the standard work of identification that does not waste their time or energy, not to mention the staff's time and energy

    Whatever you think the role of JC is, be aware that much of what they have done over the years has not been well received or productive to the goal of quality. They should be commended for finally, possibly, understanding that setting goals is one thing; attaining them is another. Translating goals to the frontline is the key. And, thus, we welcome Lean into the fray

    Mark Jaben, MD

  8. Mark Welch says:

    Don't know if you noticed this above, Mark J., but I AM a patient – have been many times – for knee surgeries (4), cancer (1), abdominal issues (1) – and I also work in healthcare. And if there is a reasonable chance, which there is, that I might be misidentified I want them to ask for verbal confirmation as long as I am lucid. I know I am a sample size of just one, but I hope I would matter. I agree that a larger sample size is necessary, though.

  9. Anonymous says:

    I always thought the second part of the goal was confusing for patients who can't identify themselves. Like you're supposed to get a nurse to verify the ID if the patient is sedated. Is that really better or necessary if you're already using a barcoded armband?
    It does seem like a workaround for a faulty ID system. Maybe the emphasis on active involvement should be on the front end, when the patient is first getting their armband?

  10. Jeff Hajek says:

    Just a thought–why should there be a different process for a conscious patient and an unconscious one? Doesn't having multiple processes increase the risk of an error?

    If the process is foolproofed for the incapacitated patient, it should also be foolproofed for the verbal one.

    I'd hate to think that my hospital would be more likely to make a mistake when I am in a worse condition and need perfection the most.

    I'm not saying don't ask the patient. I'm saying eliminate the need to ask the patient.

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