Nov 02, 2014
By Michelle Freeman, RN, PhD, CPPS

Matching the right patient to the right care

Q: I’ve just started my first job. The pace is faster than I expected. I’m afraid I’ll make an error and give medications to the wrong patient.

A: Patient misidentification creates serious problems in our health-care system. Making sure you match the right patient to the right care seems like an obvious safeguard, but I’ve discovered that new and seasoned nurses don’t necessarily understand and follow this safe and effective practice. Patients have had devastating outcomes as a result of being given the wrong medications or of receiving treatments that weren’t meant for them. The root cause of these adverse events is a lack of understanding of the patient identification process on the part of health-care professionals.

Consider this all-too-typical scenario: an RN prepares an oral dose of 5 mg of Coumadin to be administered to Jack Smith, a patient she has been caring for all day. She checks to make sure she has the right medication and right dose. She is busy, and her shift is almost over. She enters the semi-private room without the MAR (medication administration record). She asks the patient for his full name and date of birth and verifies this information with what she sees on his arm band. She administers the medication and leaves the room to sign the MAR. When she realizes she has given the Coumadin to the wrong patient, she immediately reports the error. An investigation is launched.

Not sure how and when you need to identify patients? Follow a two-step process consistently. The first step is to reliably identify the individual as the person for whom the service or treatment is intended. The second step is to match the service or treatment to that individual. Identifying a patient by facial recognition, because you verified who the person is earlier that day, does not guarantee that you are matching the patient to the treatment. A common example, as outlined in the scenario, is the nurse who administers medications without taking the MAR to the bedside. Her rationale is that she has provided care for this patient all day and knows him well. But in not verifying that the treatment was the right one for this patient (using the MAR), she omitted the critical second step.

Policies that mandate the use of two unique patient identifiers are now common in health-care settings. Typically, the identifiers are the patient’s full name and date of birth or medical record number. These must be verified as belonging to the individual and then matched with medications, blood products, specimen containers, lab requisitions and all other treatments and procedures. A room number is never an appropriate identifier.

When able, patients should be actively involved in the process of obtaining the identifiers and encouraged to identify themselves. Ask, “What is your first and last name? What is your date of birth?” Never prompt the patient: “Are you Jack Smith?” Verify that the arm band has the correct patient information if it is the source of the identifiers.

Nurses need to be reminded of the risks related to patient misidentification and assume a leadership role in ensuring that the practice of identifying the right patient and the right care is understood and always adhered to.

Michelle Freeman, RN, PhD, CPPS, is an Assistant Professor in the Faculty of Nursing, University of Windsor; a co-investigator in the Nursing Health Services Research Unit, McMaster University site; and a consultant in patient safety and quality improvement.



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