Is this the right patient? An educational initiative to improve compliance with two patient identifiers.

Mollon DL, Fields WL Journal of Continuing Education in Nursing. 40(5):221-7, 2009 May. A rehabilitation nursing unit implemented an educational initiative to improve compliance with two patientidentifiers. The education consisted of a poster presentation and then, 2 months later, a mandatory in-service education program. Compliance with two patient identifiers improved, although more improvement was demonstrated after the mandatory in-service. The results of this performance improvement project suggest that investing time and money in safety initiatives improves staff practice patterns. Implementation of patient safety strategies in European hospitals. Sunol R, Vallejo P, Groene O, Escaramis G, Thompson A, Kutryba B, Garel P Quality & Safety in Health Care. 18 Suppl 1:i57-61, 2009 Feb. CONTEXT: This study is part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on cross-border care, investigating quality improvement strategies in healthcare systems across the European Union (EU). AIM: To explore to what extent a sample of acute care European hospitals have implemented patient safety strategies and mechanisms and whether the implementation is related to the type of hospital. METHODS: Data were collected onpatient safety structures and mechanisms in 389 acute care hospitals in eight EU countries using a web-based questionnaire. Subsequently, an on-site audit was carried out by independent surveyors in 89 of these hospitals to assess patient safety outputs. This paper presents univariate and bivariate statistics on the implementation and explores the associations between implementation of patient safety strategies and hospital type using the chi(2) test and Fisher exact test. RESULTS: Structures and plans for safety (including responsibilities regarding patient safety management) are well developed in most of the hospitals that participated in this study. The study found greater variation regarding the implementation of mechanisms or activities to promote patient safety, such as electronic drug prescription systems, guidelines for prevention of wrong patient, wrong site and wrong surgical procedure, and adverse events reporting systems. In the sample of hospitals that underwent audit, a considerable proportion do not comply with basic patient safety strategies--for example, using bracelets for adult patient identification and correct labelling of medication. Nursing Management. 40(4):37-41, 2009 Apr. [back to top] Designing evidence-based patient safety interventions: the case of the UK 's National Health Service hospital wristbands. Sevdalis N, Norris B, Ranger C, Bothwell S, Wristband Project Team Journal of Evaluation in Clinical Practice. 15(2):316-22, 2009 Apr. RATIONALE, AIMS AND OBJECTIVES: Current evidence suggests that hospital inpatientidentification wristbands are not used optimally. Here we report a project by the National Patient Safety Agency (NPSA) to inform guidance development to hospitals regarding wristband specifications.METHOD: A survey assessed (i) the information on wristbands; (ii) the processes of issuing/checking/applying wristbands onto patients; (iii) the types/designs of wristbands (including colour-coding); and (iv) the main problems faced by staff face in relation to wristbanding patients.RESULTS: Responses from 166 staff members from 62 hospitals in England and Wales were collected. Information: most participants reported using the patients' first and last names, their date of birth and their local hospital number. The National Health Service (NHS) number, which is a unique identifier for each patient, is used by 37% of the respondents. Issuing process: wristbands are issued on admission or at Emergency Departments. Trained or untrained staff are involved in issuing/checking/applying wristbands onto patients, without significant problems. Colour-coding: 29/36 multiple-respondent

hospitals and 15/16 single-respondent hospitals use colour-coded wristbands to indicate special patient status (e.g. allergies). Colour-coding is not used consistently: four colours are used to signal risk of fall; red is used to signal at least 10 different statuses/risks. CONCLUSION: The NPSA recommends that wristbands should include patient's last and first name, date of birth and NHS number. They should be printed/written in black against white background. Only red colour should be used to signal special patient status. These recommendations are consistent with current developments in patient identification, and will be evaluated. Closing the safety loop: evaluation of the National Patient Safety Agency's guidance regarding wristband identification of hospital inpatients. Sevdalis N, Norris B, Ranger C, Bothwell S, Wristband Project Team Journal of Evaluation in Clinical Practice. 15(2):311-5, 2009 Apr. RATIONALE, AIMS AND OBJECTIVES: Wristbands are essential for accurate patient identification. Some evidence suggests that missing wristbands is not an infrequent occurrence in acute hospitals. The National Patient Safety Agency (NPSA) has developed guidance on patient identification for hospitals in England and Wales . Here we report an evaluation of the uptake of the guidance.METHOD: The evaluation was designed as a 'pre-post' intervention survey. Fifty hospitals (response rate 67%) responded to the 'preguidance' part and 40 hospitals (response rate 43%) responded to the 'post-guidance' part. RESULTS: The majority of the hospitals use wristbands to identify inpatients. Fifty-eight per cent of the hospitals in the 'pre-guidance' survey and 50% of them in the 'post-guidance' survey reported not having a patient identification policy before receiving the guidance. Only one hospital reported not having developed such a policy in the 'post-guidance' survey. Ninety-eight per cent of the hospitals reported that their policies are consistent with the guidance. Relevant training to staff is provided in about a quarter of the organizations, both before and after the guidance. Problems in implementing the guidance were reported by 23% of the hospitals, and included difficulties with staff orpatient attitudes, or with the guidance itself, or difficulty to identify a lead staff member. CONCLUSION:Overall, implementation of NPSA guidance regarding inpatient identification was satisfactory. The reported problems should be taken into account, as they likely apply to a range of patient safety interventions. Limitations of evaluating intervention uptake, rather than efficacy, and relying on self-report are discussed. [back to top] Identify yourself. Using palm vein scanning to ID patients fits right in with the innovative culture at BayCare. Lawrence D Healthcare Informatics. 26(4):42-5, 2009 Apr. Quickly identifying patients can give a new EMR more bang for the buck. If you don't have all the answers, reach out via the Internet and networking. Using a novel approach to demonstrate a new technology to the organization can have fantastic results. Clarity around patient identification leads to continuity in care. The culture of innovation starts at the top. An offsite with speakers can encourage innovative thought. Originality and creativity go hand in hand with risk. Rewarding behaviors and celebrating success lead to a culture of innovation. Who are you? Plucked from science fiction, palm-vein patient authentication is a cutting-edge technology that can yield major cost avoidance. Lawrence D Healthcare Informatics. 26(3):32, 34-5, 2009 Mar. Palm vein authentication is a very accurate form of biometric patient identification. One ROI is cost avoidance of adverse events due to incorrect medical records. Biometrics can position a hospital as a technology leader in the community. Cradles for scanning the hand should be

adjusted depending on the patient's point of entry. CIOs who are using it say it is an easy implementation with low maintenance and training. Patients tracking and identifying inside hospital: a multilayer method to plan an RFId solution. Iadanza E, Dori F, Miniati R, Bonaiuti R Conference Proceedings: ... Annual International Conference of the IEEE Engineering in Medicine &Biology Society. 2008:1462-5, 2008. This paper shows a method to get a patient tracking RFId solution, basing on a multilayer planning architecture. This approach is thought to guarantee that the found technical solution is as much as possible coherent to the very initial idea. Project aims, functional requirements and technical constraints are defined in order to arrive to an active RFId solution to track and identify patients inside a hospital. The article also deals with economical issues and physical design aspects. In this work it's also defined a three phases process for patient tracking, that could serve as a guideline for different technical solutions to the same problem. [back to top] Design of RFID based the Patient Management and Tracking System in hospital. Kim DS, Kim J, Kim SH, Yoo SK Conference Proceedings: ... Annual International Conference of the IEEE Engineering in Medicine & Biology Society. 2008:1459-61, 2008. The patient location information in managing for patient workflow will be worked efficiently within the hospital. We designed the Patient Management and Tracking System (PMTS) based on RFID with RSSI(Received Signal Strength Indication) method. This system is able to track the movement ofpatient in hospital, and manage the waiting-list of patients at a medical office. Therefore, we are sure that the PMTS will be useful for decreasing a duty of medical staff and increase a convenience of patients. Hospital automation system RFID-based: technology embedded in smart devices (cards, tags and bracelets). Florentino GH, Paz de Araujo CA, Bezerra HU, Junior HB, Xavier MA, de Souza VS, de M Valentim RA, Morais AH, Guerreiro AM, Brandao GB Conference Proceedings: ... Annual International Conference of the IEEE Engineering in Medicine & Biology Society. 2008:1455-8, 2008. RFID is a technology being adopted in many business fields, especially in the medical field. This work has the objective to present a system for automation of a hospital clinical analysis laboratory. This system initially uses contactless smart cards to store patient's data and for authentication of hospital employees in the system. The proposed system also uses RFID tags stuck to containers containing patient's collected samples for the correct identification of the patient who gave away the samples. This work depicts a hospital laboratory workflow, presents the system modeling and deals with security matters related to information stored in the smart cards. Identity in the PALM of your hand. McBride M Mlo: Medical Laboratory Observer. 41(2):22-3, 2009 Feb [back to top] RFID in the healthcare supply chain: usage and application. Kumar S, Swanson E, Tran T International Journal of Health Care Quality Assurance. 22(1):67-81, 2009. PURPOSE: The purposes of this study are to first, determine the most efficient and cost effective portions of the healthcare supply chain in which radio frequency identification devices (RFID) can be implemented. Second, provide specific examples of RFID implementation and show how these business applications will add to the

effectiveness of the healthcare supply chain. And third, to describe the current state of RFID technology and to give practical information for managers in the healthcare sector to make sound decisions about the possible implementation of RFID technology within their organizations. DESIGN/METHODOLOGY/APPROACH: Healthcare industry literature was reviewed and examples of specific instances of RFID implementation were examined using an integrated simulation model developed with Excel, @Risk and Visio software tools. FINDINGS: Analysis showed that the cost of implementing current RFID technology is too expensive for broad and sweeping implementation within the healthcare sector at this time. However, several example applications have been identified in which this technology can be effectively leveraged in a cost-effective way. PRACTICAL IMPLICATIONS: This study shows that RFID technology has come a long way in the recent past and has potential to improve healthcare sector productivity and efficiency. Implementation by large companies such as Wal-mart has helped to make the technology become much more economical in its per unit cost as well as its supporting equipment and training costs. ORIGINALITY/VALUE: The originality of this study lies in the idea that few practical and pragmatic approaches have been taken within the academic field of study for the implementation of RFID into the healthcare supply chain. Much of the research has focused on specific companies or portions of the supply chain and not the entire supply chain. Also, many of the papers have discussed the future of the supply chain that is heavily dependent on advances in RFID technology. A few viable applications of how RFID technology can be implemented in the healthcare supply chain are presented and how the current state of technology limits the broad use and implementation of this technology in the healthcare industry. Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback Garnerin P, Ares M, Huchet A, Clergue F Quality & Safety in Health Care. 17(6):454-8, 2008 Dec. BACKGROUND: The potential severity of wrong patient/procedure/site of surgery and the view that these events are avoidable, make the prevention of such errors a priority. An intervention was set up to develop a verification protocol for checking patient identity and the site of surgery with periodic audits to measure compliance while providing feedback. ASSESSMENT OF PROBLEM: A nurse auditor performed the compliance audits in inpatients and outpatients during three consecutive 3-month periods and three 1-month follow-up periods; 11 audit criteria were recorded, as well as reasons for not performing a check. STRATEGY FOR CHANGE: The nurse auditor provided feedback to the health professionals, including discussion of inadequate checks. RESULTS: 1,000 interactions between patients and their anaesthetist or nurse anaesthetist were observed. Between the first and second audit periods compliance with all audit criteria except "surgical site marked" noticeably improved, such as the proportion of patients whose identities were checked (62.6% to 81.4%); full compliance with protocol inpatient identity checks (9.7% to 38.1%); proportion of site of surgery checks carried out (77.1% to 92.6%); and full compliance with protocol in site of surgery checks (32.2% to 52.0%). Thereafter, compliance was stable for most criteria. The reason for failure to perform checks of patient identity or site of surgery was mostly that the anaesthetist in charge had seen the patient at the preanaesthetic consultation. LESSONS AND MESSAGES: By combining the implementation of a verification protocol with periodic audits with feedback, the intervention changed practice and increased compliance withpatient identity and site of surgery checks. The impact of the intervention was limited by communication problems between patients and professionals, and lack of collaboration with surgical services. [back to top] Medical errors and patient safety. Issue brief. Whitehead A Issue Brief - Health Policy Tracking Service. :1-21, 2009 Jan 5 Smart health cards or health smart cards?[comment].

Leggat SG Australian Health Review. 33(1):3, 2009 Feb. Health smart cards: differing perceptions of emergency department patients and staff Mohd Rosli R, Taylor DM, Knott JC, Das A, Dent AW Australian Health Review. 33(1):136-43, 2009 Feb. An analytical, cross-sectional survey of 270 emergency department patients and 92 staff undertaken in three tertiary referral hospital emergency departments was completed to compare the perceptions of patients and staff regarding the use of health smart cards containing patient medical records. The study recorded data on a range of health smart card issues including awareness, privacy, confidentiality, security, advantages and disadvantages, and willingness to use. A significantly higher proportion of staff had heard of the card. The perceived disadvantages reported by patients and staff were, overall, significantly different, with the staff reporting more disadvantages. A significantly higher proportion of patients believed that they should choose what information is on the card and who should have access to the information. Patients were more conservative regarding what information should be included, but staff were more conservative regarding who should have access to the information. Significantly fewer staff believed that patients could reliably handle the cards. Overall, however, the cards were considered acceptable and useful, and their introduction would be supported. Radio frequency identification. Westra BL American Journal of Nursing. 109(3):34-6, 2009 Mar Identity in the palm of your hand. McBride M Health Management Technology. 30(1):16-9, 2009 Jan. You can access recent issues of this journal online - contact the Library for a password. Click here to go to the journal: http://proquest.umi.com/pqdweb? TS=1092025720&clientId=67476&RQT=317 [back to top] Unique health ID numbers could aid quality, efficiency. anonymous Hospitals & Health Networks. 82(12):48, 2008 Dec. You can access recent issues of this journal online - contact the Library for a password. Click here to go to the journal: http://proquest.umi.com/pqdweb? TS=1092025720&clientId=67476&RQT=317 Swiping savings. MGMA renews push for machine-readable ID cards. Robeznieks A Modern Healthcare. 39(2):32, 2009 Jan 12. Testing potential interference with RFID usage in the patient care environment. Christe B, Cooney E, Maggioli G, Doty D, Frye R, Short J Biomedical Instrumentation & Technology. 42(6):479-84, 2008 Nov-Dec. The use of radio frequency identification (RFID) equipment in the clinical setting has become prevalent. The exploration of the potential interactions between the equipment used to implement RFID and medical devices is vital to ensure safe and effective use of both the tracking technology and the patientcare equipment. This study examines the effects of two common RFID antennas, Near-Field and Far-Field, and five general types of patient care

equipment. Data were collected regarding the function of the patient care equipment in the fields of the antennas. No device performance alterations were observed. Much ado about RFID. DiConsiglio J Materials Management in Health Care. 17(11):28-30, 2008 Nov. [back to top] Mixed signals. Highlighting potential dangers of RFID in hospitals. Interview by Alan Joch. Berwick DM Materials Management in Health Care. 17(11):15-7, 2008 Nov. Wristband standardization: why we aren't there yet. anonymous Healthcare Benchmarks & Quality Improvement. 15(12):131-2, 2008 Dec When a patient has no identification. Shore E Medical Economics. 85(19):38, 2008 Oct 3 Wristband standardization: why we aren't there yet. anonymous Hospital Peer Review. 33(11):147-8, 2008 Nov. 'Smart card' speeds triage, boosts safety. anonymous Ed Management. 20(10):115-6, 2008 Oct. An internally developed 'smart card' and a kiosk equipped with an electronic reader have helped Wellington (FL) Regional Medical Center speed up its triage process considerably. The new technology is extremely popular with the staff, as well as with the patients. Here are some of its benefits: Patients who have the card don't need to provide a detailed history every time they visit the ED. Nurses don't have to type in the patient's medical information. It automatically "populates" their computer screen. Security is maintained, because the information is stored in a database, and not on the card. [back to top] Maximizing patient safety utilizing effective patient identification and image labeling practices. Aloisio JJ Radiology Management. 30(5):54-9, 2008 Sep-Oct. Proper patient identification in the radiology setting is increasingly being recognized as a widespread safety issue. This article discusses the corrective action taken when a mislabeled portable image contributed to a patient's demise. Annual bedside portable exams at North Shore University Hospital exceed 60,000 procedures. Managing workload of this volume is extremely difficult and requires effective patient identification policies and procedures to ensure patient safety. Developing a safety culture across the radiology department is a critical component of patient safety. Staff education and ongoing re-enforcement of safety principles are fundamental elements to a successful program. Ethical implications of implantable radiofrequency identification (RFID) tags in humans Foster KR, Jaeger J American Journal of Bioethics. 8(8):44-8, 2008 Aug.

This article reviews the use of implantable radiofrequency identification (RFID) tags in humans, focusing on the VeriChip (VeriChip Corporation, Delray Beach, FL) and the associated VeriMed patientidentification system. In addition, various nonmedical applications for implanted RFID tags in humans have been proposed. The technology offers important health and nonhealth benefits, but raises ethical concerns, including privacy and the potential for coercive implantation of RFID tags in individuals. A national discussion is needed to identify the limits of acceptable use of implantable RFID tags in humans before their use becomes widespread and it becomes too late to prevent misuse of this useful but ethically problematic technology. A new method to guard inpatient medication safety by the implementation of RFID. Sun PR, Wang BH, Wu F Journal of Medical Systems. 32(4):327-32, 2008 Aug. Since life is invaluable, the patient safety is always an important issue. How to reduce the malpractices and advance the patient safety is the primary goal of many countries. The current problem is that the hospitals cannot quickly and precisely identify the name of medicine, the position of patient and staff and the servicing time and dosage taken by patients. The application of Radio Frequency Identification(RFID) is rocketing in popularity as varieties of expanded uses. However, due to the investment consideration, there are few cases that practically implement such a technology in healthcare industries. This paper presents a Wisely Aware RFID Dosage (WARD) system, which based on an integration of barcodes and RFID tags, to demonstrate effective and safe patient care environment, for preventing the risk of medication error. Finally, through an evaluation of users' satisfaction, a reliability of 0.92 and a criterion-related validity of 0.82 show that this system is able to effectively construct the patient-safety-centric environment. [back to top] Patient identification in three acts. Fernandes L, O'Connor M Journal of Ahima. 79(4):46-9; quiz 51-2, 2008 Apr. Patient misidentification in oncology care. Schulmeister L Clinical Journal of Oncology Nursing. 12(3):495-8, 2008 Jun. Patients with cancer are at risk for patient misidentification, or "wrong patient" incidents. Patientmisidentification can result in medication and transfusion errors, unnecessary testing or procedures, and, in some cases, death. Patients may be misidentified when nurses mispronounce their names, refer to them by their first or last names only, are complacent and fail to check armbands, or encounter language or communication barriers. Errors caused by patient misidentification can be prevented when healthcare providers consistently use two unique patient identifiers (other than the patient's room, examination, or chair number) to verify identities. The challenging nature of patient identifiers: an ethnographic study of patient identification at a London walk-in centre. Lichtner V, Wilson S, Galliers JR Health Informatics Journal. 14(2):141-50, 2008 Jun. The correct identification of a patient's health record is the foundation of any safe patient record system. There is no building of a ;patient history', no sharing or integration of a patient's data without the retrieval and matching of existing records. Yet there can often be errors in this process and these may remain invisible until a safety incident occurs. This article presents the findings of an ethnographic study ofpatient identification at a walk-in centre in the UK . We offer a view of patient identifiers as used in practice and show how seemingly simple data, such as a person's name or date of birth, are more complex than they may at first appear and how they potentially pose problems for the use of integrated health

records. We further report and discuss a dichotomy between the identifiers needed to access health records and the identifiers used by practitioners in their everyday work. Complying with the 2008 National Patient Safety Goals. Catalano K, Fickenscher K AORN Journal. 87(3):547-56, 2008 Mar. In 2003, the joint commission began publishing National Patient Safety Goals (NPSGs) and requiring accredited health care organizations to comply with these goals in an effort to reduce the number of medical errors. THE NPSGS are updated yearly with new requirements to promote specific improvements in patient safety. This article provides a review of the 2008 NPSGs and suggests ways in which information technology systems can address health care organizations' compliance with some of these goals. You can access recent issues of this journal online - contact the Library for a password. Click here to go to the journal: http://proquest.umi.com/pqdweb? TS=1092025720&clientId=67476&RQT=317, Recent issues of this journal may be available full text online [back to top] Improving patient safety--everyone's job. Patient identification: an example of how the wrong man got a bath!. Reed AS Home Healthcare Nurse. 26(2):140, 2008 Feb. RFID systems in healthcare. Emerging uses and potential issues. Dinh AK Journal of Ahima. 79(1):62-3, 2008 Jan. International Journal of Medical Informatics. 77(3):176-83, 2008 Mar. BACKGROUND: Radio frequency identification (RFID) is an emerging technology that is rapidly becoming the standard for hospitals to track inventory, identify patients, and manage personnel.METHODS: Research involved qualitative methods including participant observation and interviews with hospital staff members and industry consultants in the United States . RESULTS: Hospital staff, especially nurses, expressed concern about the surveillance potential of these tracking technologies. Additionally, nursing staff frequently experience an intensification of labor as a result of the implementation of RFID systems because the task of keeping the systems operational often falls upon them. CONCLUSIONS: The social and organizational factors that contribute to the success or failure of RFID systems in hospitals must be further analyzed. The implications of RFID systems, such as privacy concerns and work intensification for nursing and other hospital staff, should be taken into account from the outset, especially during the design and implementation of the technology. What are the benefits and risks of fitting patients with radiofrequency identification devices Levine M, Adida B, Mandl K, Kohane I, Halamka J PLoS Medicine / Public Library of Science. 4(11):e322, 2007 Nov 27. Background to the debate: In 2004, the United States Food and Drug Administration approved a radiofrequency identification (RFID) device that is implanted under the skin of the upper arm of patients and that stores the patient's medical identifier. When a scanner is passed over the device, the identifier is displayed on the screen of an RFID reader. An authorized health professional can then use the identifier to access the patient's clinical information, which is stored in a separate, secure database. Such RFID devices may have many medical benefits-such as expediting identification of patients and retrieval of their medical records. But critics of the technology have raised several concerns, including the risk of the patient's identifying information being used for nonmedical purposes. [back to top] Patient identification.

Thorpy MJ, Lieberman JA 3rd, Roth T, Owens GS American Journal of Managed Care. 13(6 Suppl):S132-9, 2007 Nov. The homeostatic sleep drive and circadian arousal, each opposing the other, form the neurobiological bases of the sleep and wake states. Many factors can and do disrupt this cycle. Yet, excessive daytime sleepiness is not only common, and it often goes unrecognized. It can contribute to accidents, produce or exacerbate health conditions, reduce efficiency and productivity, interfere with social relationships, and diminish quality of life. The spectrum of common sleep disorders includes circadian rhythm changes, shiftwork requirements, obstructive sleep apnea, narcolepsy, and difficulty in initiating or maintaining sleep, also known as insomnia. In many cases, however, sleep deprivation is the choice of the patient, chosen in response to long commutes, academic rigor, or occupational matters. Regardless of the sleep disorder that a patient has, good sleep behavior or "sleep hygiene" is essential. Color wristband program seeks to reduce errors. anonymous Healthcare Benchmarks & Quality Improvement. 14(12):138-9, 2007 Dec. Colorado collaborative adapts existing program to fit the needs of staff and patients. Focus is less on the specific identifying device than on using the appropriate colors. Quality professionals develop the program and oversee hospital implementation. Risk management. Safety advocates seek to end confusion over color-coded wristbands Rollins G Hospitals & Health Networks. 81(10):14, 16, 2007 Oct. You can access recent issues of this journal online - contact the Library for a password. Click here to go to the journal: http://proquest.umi.com/pqdweb? TS=1092025720&clientId=67476&RQT=317 Real ID Act and Radio Frequency Identification Devices (RFID): the future of patient identification?. Moore DH, French DD Journal of the American Medical Directors Association. 8(8):551, 2007 Oct. [back to top] Technology. Hospitals now use palm readers for patient identification. Registration may be streamlined, but some wonder if it's worth the cost. McKinney M Hospitals & Health Networks. 81(9):30, 2007 Sep. You can access recent issues of this journal online - contact the Library for a password. Click here to go to the journal: http://proquest.umi.com/pqdweb? TS=1092025720&clientId=67476&RQT=317 Radio frequency identification for prevention of bedside errors. Dzik S Transfusion. 47(2 Suppl):125S-129S; discussion 130S-131S, 2007 Aug. Application of bar code technology at the bedside: the Oxford experience. Murphy MF Transfusion. 47(2 Suppl):120S-124S; discussion 130S-131S, 2007 Aug Hospitals must standardise patients' wristbands to reduce risk of wrong care. Mayor S BMJ. 335(7611):118, 2007 Jul 21.

[back to top] Auto identification technology and its impact on patient safety in the Operating Room of the Future. Egan MT, Sandberg WS Surgical Innovation. 14(1):41-50; discussion 51, 2007 Mar. Automatic identification technologies, such as bar coding and radio frequency identification, are ubiquitous in everyday life but virtually nonexistent in the operating room. User expectations, based on everyday experience with automatic identification technologies, have generated much anticipation that these systems will improve readiness, workflow, and safety in the operating room, with minimal training requirements. We report, in narrative form, a multi-year experience with various automatic identificationtechnologies in the Operating Room of the Future Project at Massachusetts General Hospital. In each case, the additional human labor required to make these ;labor-saving' technologies function in the medical environment has proved to be their undoing. We conclude that while automatic identificationtechnologies show promise, significant barriers to realizing their potential still exist. Nevertheless, overcoming these obstacles is necessary if the vision of an operating room of the future in which all processes are monitored, controlled, and optimized is to be achieved. This year's models. A look at patient ID in the four newly demonstrated NHIN prototypes. Rollins G Journal of Ahima. 78(3):34-7; quiz 39-40, 2007 Mar. Identifying patients in hospital: are more adverse events waiting to happen?. Perry DC, Scott SJ Quality & Safety in Health Care. 16(2):160, 2007 Apr. Patient identification: hybrids and doppelgangers. Cummins D Annals of Clinical Biochemistry. 44(Pt 2):106-10, 2007 Mar. Safe laboratory practice requires accurate patient identification. Adverse events may occur when apatient has identifiers similar or identical to those of another patient (a 'doppelganger'), is doubly registered (a 'duplicate registration'), or when registration details are derived from two or more separate sources (a 'hybrid registration'). Distinguishing doppelgangers from duplicate registrations is not always easy. A search of the Harefield Hospital Patient Administration System (PAS) database revealed 39 registrations that shared a forename, surname and date of birth with at least one other registration. Thirty-seven of these cases involved a duplicate registration, one involved a hybrid registration, and one involved a doppelganger. The National Strategic Tracing Service can help with resolution of difficult cases. Many serious patient identification errors involve what the Serious Hazards of Transfusion (SHOT) Report refers to as 'extraordinary' coincidences of patients with similar names. Such coincidences are, in fact, not extraordinary, but ordinary. A major challenge will be to establish how adverse events involving coincidence can be described in a way that does not create the impression of extraordinary bad luck. You can access recent issues of this journal online - contact the Library for a password. Click here to go to the journal: http://proquest.umi.com/pqdweb? TS=1092025720&clientId=67476&RQT=317 [back to top]

http://www.health.nsw.gov.au/quality/identification/ literature.asp#8