A "Step Backward" in Patient Safety?
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.
“…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.