August 20, 2007

Patient Safety: It’s All in the Wrist
By Deborah Murphy
For The Record
Vol. 19 No. 17 P. 8

Once again, in 2008, “improving the accuracy of patient identification” tops the list of The Joint Commission’s National Patient Safety Goals for hospitals. A recurring theme since 2003, the goal requires the use of two or more patient identifiers when administering medications and blood products or taking blood samples.

Fortunately for hospitals and health systems, there is a straightforward solution. A bar-coded wristband can reliably and confidentially meet the recommended positive patient identification requirements. The Joint Commission formally acknowledges this approach on its Web site: “The two identifiers may be in the same location, such as a wristband. ... Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier. Bar coding that includes two or more person-specific identifiers (not room number) will comply with this requirement.”

Bar Code Basics and Beyond
Positive patient ID is a most basic requirement. Imagine an x-ray technician telling his replacement during the shift change, “Can you take my last patient and give a portable chest x-ray to Mrs. Johansson down the hall?” The new technician then takes the equipment down the hall, sees a patient room marked “Johnson,” and enters to take the x-ray. With an informal process, there are thousands of reasons why the wrong patient may receive the wrong diagnostic test or, much worse, surgical procedure or treatment.

Bar code scanning is accurate, more so than any manual process. Studies have shown that skilled typists average one error per 300 keystrokes. Bar code data entry errors, by comparison, occur less than once per 3 million scans. This kind of precision applied to patient identification pays off in healthy outcomes, financial performance, and risk reduction.

Beyond basic positive patient ID as a compliance measure, bar-coded wristbands serve as a foundation for automating and streamlining clinical processes and operations in other areas, including the following:

• Medication administration. Verifying “the five rights” at the bedside—right patient, right medication, right dose, right time, and right method of administration—prevents many adverse drug events. With electronic medication administration record systems, the nurse scans the patient’s wristband, scans or enters relevant data from the unit-dose medication container, and scans his or her own ID badge. The system automatically confirms the five rights and documents the encounter. The FDA estimates that the use of such systems would intercept 50% of all medication administration errors, though in practice, many organizations report results of 80% and higher.

• Blood dispensing. The process for verifying that patients receive the right blood products is similar to the process for medication administration. And because all blood products must carry a standardized bar code identifier, it’s fairly easy to implement scan-based checks at the bedside. On average, there are 414 annual transfusion errors in the United States, or roughly one in 38,000 transfusions. According to the FDA, the incidence of adverse drug events can reach 1.25 million each year. The maturity in bar code identification in blood collection, processing, and distribution may help explain this disparity.

• Specimen collection. Barcoding is an important quality assurance tool for tracking medical samples. Before taking a sample, a nurse scans the patient’s wristband and checks a mobile computer to verify that the sample is needed and hasn’t already been taken. While the sample is being drawn, a mobile printer automatically generates a patient-specific bar-coded ID label, which is applied to the sample immediately to minimize the risk of misidentification.

• Billing and administrative activities. Timesaving and service-enhancing benefits also can be gained in various nonmedical activities. For example, the wristband bar code can serve as a credit card to be scanned to capture charges. Bar-coding can even make hospital food more palatable: At some facilities, foodservice workers scan patients’ wristbands and enter their order into a handheld device. This process ensures that patients receive what they requested and better serves those with food allergies.

Building a Better Wristband
The attributes of a good wristband are easy to understand but surprisingly difficult to attain. Numerous studies have shown that between 2% and 6% of patients are not properly identified by their wristbands. To address this challenge, healthcare providers must utilize wristbands that are durable, stay on the patient’s wrist, and remain readable throughout the hospital stay. The wristbands also must uniquely identify the patient in a HIPAA-compliant manner.

There are the following four key considerations to keep in mind:

1. What information will be included on the wristband? A bar code is often an alternative to representing text-based information. Anything printed on a wristband can be encoded as well. The most basic bar codes are keys that refer to a record in a database. When scanned, the reference number instructs a computer to look up or update the corresponding patient data. Because bar codes store data in less space than is required for the equivalent text, bar-coded wristbands can include more information than traditional text wristbands.

2. What kind of bar code will be used to encode it? The wristband’s information content is the key factor in determining the type of bar code to use and how to produce the wristband itself. The more frequently a patient needs to be accessed, the more it makes sense to encode that information directly on the wristband. For more advanced applications, bar codes can represent actual alpha-numeric data. Two-dimensional bar codes can store exponentially more information in a given area, capturing on the wristband the patient’s blood type, allergies, primary physician, demographics, or even an encoded digital photograph, viewable on a PC or portable computer.

Additionally, 2-D bar codes run across the entire wristband, so caregivers don’t need to overtly disturb the patient to get a scan. In fact, the patient comfort factor is prompting more hospitals to seriously consider 2-D as they adopt bar-coded wristbands.

3. How should the wristband be printed? Bar codes can be printed directly on wristbands or as separate labels to be applied by hand. Either thermal or laser printers can print wristbands. While laser printers are typically already in use in admissions departments and nursing stations, printing wristbands on demand with thermal printers eliminates the need to feed through an entire form that includes other labels that are often thrown away. In addition to minimizing waste, using a thermal printer for bar-coded wristbands helps keep down the toner cost on the laser printer, as the density of bar codes requires significantly more toner than standard documents.

4. What material should be used? Missing wristbands are the most common error identified in every published study on the subject. However, there are many secure, durable wristband materials that allow for direct printing of bar codes and text. Some vendors even offer wristbands with an antimicrobial coating that protects bands from infection-causing bacteria.

When selecting materials, it is also important to consider all the potential exposures and usage conditions. Moisture, soaps, foam washes, temperature extremes, and repeated handling all have the potential to damage images, dissolve adhesives, or destroy the wristband. Output from inappropriate printers on substandard materials may result in fading, smudges, scratches, or wrinkles that render bar codes useless.

Looking Ahead
In today’s fast-paced healthcare environment, bar-coded wristbands provide the foundation upon which organizations can establish a safer, more efficient process for delivering care. They not only help healthcare facilities comply with Joint Commission and HIPAA requirements, but they also position hospitals for dramatic safety and quality improvements. When it comes to ensuring positive patient ID, bar coding affords a practical route to accuracy, consistency, and efficiency.

— Deborah Murphy is the global practice leader for life sciences at Zebra Technologies and a member of the HIMSS Auto ID Task Force.