Dear Colleagues,
As you all know, patient safety is the responsibility of everyone here at UHN. Patient misidentification accounts for many of the incidents that we investigate- fortunately many of these incidents are near misses. However, failure to properly identify our patients can create adverse events such as medication errors, blood transfusion errors, diagnostic testing errors, wrong person procedures, etc. Accreditation Canada has set forth standards regarding the use of two client identifiers to ensure positive patient identification (PPID) and patient safety. We are following these standards as follows:
- The first is the verbal confirmation that you have the right person using two identifiers (MRN + full name or full name + MRN/DO
- The second component is to use the same two identifiers to confirm that the service or procedure was intended for the specific patient – checking ID against a source like the blue card, wristband, requisitions, and labels.
At UHN, we need to ensure that follow this policy and use the same two client identifiers consistently in any given environment.
With the inpatient population we use addressograph wrist bands. TGH has started a pilot project in the inpatient area using a new barcode wrist band technology printed from EPR. This new wrist band allows scanning the barcode to verify patient identity with specific procedures. Roll out dates for TWH and PMH will occur early 2012 and it is currently in use with inpatients at some of our TRI sites.
In the out-patient areas we will not use wrist banding for all patients but we will ensure we are using addressograph wrist banding according to our current policies and procedure (patients need wrist bands if they are undergoing procedures requiring anesthesia or conscious sedation, blood transfusions, interventional treatment, therapy requiring unique consent and whenever a potential for radical change in health status exists).
For all other ambulatory patients we will use the blue addressograph card. When the patient presents in out-patients with the blue card- you should check the spelling of their full name and DOB on the card while verbally confirming the personal information with the patient and then check full name & DOB against a second source (EPR, PHS, labels, requisitions, etc) to ensure they match.
As we approach our Accreditation surveyors' visit in November, we will be scheduling staff information sessions, distributing patient education pamphlets, and posting posters. The Clinical VP's, Clinical Directors, Managers and Educators will lead targeted education and develop processes to ensure that we are all following proper positive patient identification procedures.
We need your help in keeping our patients safe.
Bob
