JACR: New system curbs patient ID errors
A four-step process reduced patient identification errors in medical imaging and offered a useful, easy, quick and relevant process for staff members, according to a study published in the August issue of Journal of American College of Radiology.

Adverse events are linked with up to 16.6 percent of hospital admissions and half are considered preventable, noted Luke A. Danaher, MBBS, of the department of medical imaging research and education at Royal Brisbane & Women’s Hospital in Herston, Australia. Earlier data identified radiology as the second most common hospital department to perform wrong-site procedures and suggested that wrong patient exams account for one-quarter of radiology errors.

“Although these studies illustrate the scale of medical error, they also represent an opportunity for error prevention through systems improvement,” wrote Danaher.

Danaher and colleagues developed a system of ensuring that imaging exams are performed on the correct patient, correct site and side, and as the correct procedure (the 3 C’s).

The four step process includes:
  1. Patient identification. Patients provide their full names, dates of birth and indications each time they present to a new staff member.
  2. Informed consent. The radiologist or registrar collects written consent prior to the procedure, and patients are provided an opportunity to ask questions.
  3. Correct site and side verification. Patients provide the site and side of the procedure, which the registrar marks and signs if appropriate. For nonprocedural (noninterventional) exams, the correct site and side are confirmed and recorded by the technologist.
  4. Final check. The radiologist or registrar verifies the patient’s name, date of birth, procedure, site and consent prior to interventional procedures. The technologist follows a similar process for nonprocedural studies.

In the case of unconscious, uncooperative or noncommunicative patients, a nurse or physician confirms the patient’s identity and exam details.

The process was piloted for six months beginning in January 2008 at three interventional radiology sites. During the pilot, 170 staff members including radiologists, techs, orderlies and administrators were trained, and one-on-one training was provided for interventional radiologists.

After the pilot, Danaher and colleagues reported 95 percent to 100 percent verification of site and side and 100 percent verification of correct patient, procedure and consent. However, a change in reporting systems confounded the researchers’ attempts to compare pre- and post-pilot incidents.

A compliance audit at six weeks showed that 100 percent of patient request forms were final-checked, identified and signed; however, staff members admitted that in some cases, forms are signed prior to patient arrival in the department or hours after the procedure. “Whether this indicates the need for audit design improvement, a different method of presenting audit results, or placing emphasis on effort and participation rather than compliance is yet to be seen,” offered Danaher et al.

Another stumbling block centered on incorrect patient identification stickers on request forms. The team devised a processes solution using a new request form with an integrated final documentation section. The new system works, confirmed Danaher et al, but old forms are still submitted. This issue may be ongoing, noted the researchers, as electronic documentation is prone to similar errors. They identified the need for further research into these types of administrative errors.

The researchers emphasized the role of teamwork and leadership in change management. Constructive feedback and praise from senior staff members and the auditing team helped them overcome some early initial resistance to the project, they explained.

They also noted the possibility of the Hawthorne effect, whereby performance improves because staff members are aware they are being observed.

A survey of staff members indicated that most agreed that the final check is quick and easy to perform as well as relevant and likely to reduce errors in medical imaging, offered Danaher and colleagues. One complaint about the project stemmed from interventional radiologists’ non-compliance with final check paperwork, which led to the need to track them to complete the paperwork. “This is an area that needs to be addressed because even the simplest administrative, process or leadership error can have a significant effect,” wrote Danaher et al.

The researchers pegged several keys to success: an ongoing commitment to education, process improvement, incident reporting and positive leadership. They wrote, “Although identification error is difficult to eliminate, practical initiatives can engender significant improvement in complex healthcare environments.”