1. Patient Identifiers Quality Improvement Plan Project Alan Gutberlet, Joaquin Hall, VanjaJonjic, Joseph Liska and Melanie Williams

2. Description of the Problem • Monitoring patient identifiers is one of The Joint Commission’s National Patient Safety Goals (NPSG) • Improve patient safety • Requires two unique patient specific identifiers • Ensure the patient is the person who is to be treated • Handful of incidents of incorrect patient identification (no harm done) • Wrong patient received CT scan • Food delivered to wrong patient – delayed procedure • Survey delivered to wrong patient

3. Significance of the Problem • Reduce Errors • Medication administration errors • Wrong patient/wrong surgery • Wrong site surgeries • Wrong test/wrong patient • Blood transfusion errors • Wrong nutrition • Improve patient safety

4. Literature Support & Analysis • Several methodologies available for implementation • Plan-Do-Study-Act (PDSA) • Focus-Analyze-Develop-Execute-Evaluate (FADE) • Six Sigma • Improved data collection and monitoring ensures accountability and correctly identifies sources of errors • Policies should be simplified to prevent information overload

5. Literature Support & Analysis II • Patient wristbands not enough by themselves • Patient safety team provided awareness, training, and increased monitoring • Technology can help, but still a human error and accountability problem • Continual monitoring of reliable indicators required

6. Proposed Solutions - Implementation • Implementation is key • Leaders must battle resistance to change • Provide incentives for change • Leaders send strong signal of support of change • Policies • Simplify • Train • Monitor/Evaluate • Invest in Information Technology & monitoring • Create evaluation system for identification errors and ensure accountability • Data collected helps guide changes

7. Proposed Solutions - Maintain • Change culture • Create a learning organization • Reduce social loafing – everyone is responsible for patient identification • Isolate negative outcomes, and reinforce positive outcomes • Continual monitoring • Continually evaluate monitoring to ensure reliability and accuracy of data • Re-evaluate goals

8. Conclusion/Recommendations • Patient safety should be a part of the organization’s culture • Policies and procedures need to be simplified and created with the effected parties • Monitoring should be re-evaluated and updated to be more reliable • Training and auditing are required to ensure compliance • Implementation and securing buy in are critical to success

9. Lessons Learned • Having a goal is not by itself enough to guarantee the goal is met • Requires leadership to implement • Requires employee’s buy in • Just because you have data does not mean it is reliable • Sample size needs to be large enough to be meaningful • Sampling locations need to be diverse enough to get an accurate sample • Data must measure what you intended to measure • Too many complicated policies can have a negative effect • Information overload – need to simplify • Must analyze all effects of policies

10. References Alexander, Jeffrey A., et al. "Organizational structure for addressing the attributes of the ideal healthcare delivery system." Journal of Healthcare Management Nov.-Dec. 2008: 407+. Health Reference Center Academic . Web. 29 June 2012. Dhatt, G. S., Damir, H., Matarelli, S., Sankaranarayanan, K., & James, D. M. (2011). Patient safety: patient identification wristband errors. Clinical Chemistry & Laboratory Medicine, 49( 5), 927-929. doi:10.1515/CCLM.2011.129 Duke University Medical Center. (2005). Patient safety - quality improvement. What is quality improvement? Retrieved from Department of community and family medicine: http://patientsafetyed.duhs.duke.edu/module_a/methods/fade.html Institute for Healthcare Improvement. (2011, July 7). Pareto diagram. Retrieved from the Institute for healthcare improvement: http://www.ihi.org/knowledge/Pages/Tools/ParetoDiagram.aspx Institute for Healthcare Improvement. (2011, April 24). Science of improvement: Establishing measures. Retrieved from IHI: http://www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx Khalighi, M. (2007, August). Basics of quality improvement. Retrieved from: http://depts.washington.edu/uwmedres/patientcare/objectives/hospitalist/Quality_Improvement_BasicsBasics.pdf Lichtner, V., Wilson, S., Galliers J. R. (2008). The challenging nature of patient identifiers: an ethnographic study of patient identification at a London walk-in centre.Health Informatics Journal, 14 (2), 141-149. Doi: 10.1177/1081180X08089321 McCaughrin, William C., & Olden, Peter C. "Designing healthcare organizations to reduce medical errors and enhance patient safety." Hospital Topics Fall 2007: 4+.Health Reference Center Academic . Web. 29 June 2012. Mollon, D., & Fields, W. (2009). Is this the right patient? An educational initiative to improve compliance with two patient identifiers. Journal Of Continuing Education In Nursing, 40(5), 221-227. doi:10.3928/00220124-20090422-03 National Institute of Standards and Technology. (2010, September 13). Baldridge performance excellence program. Retrieved from NIST: http://www.nist.gov/baldrige/about/baldrige_faqs.cfm O'Daniel, M., & Rosenstein, A.H. (2008, April). Professional communication and team collaboration. Patient safety and quality: An evidence-based handbook for nurses. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2637/ Parisi, L. (2003). Patient identification: the foundation for a culture of patient safety. Journal Of Nursing Care Quality, 18 (1), 73-79. Ransom, E. R., Joshi, M. S., Nash, D. B., & Ransom, S. B. (2009). The healthcare quality book, vision, strategy, and tools. (2 ed.). Washington, DC: Health Administration Press The joint commission. (2011 , December 11). Hospital: 2012 national patient safety goals. Retrieved from The joint commission: http://www.jointcommission.org/standards_information/npsgs.aspx The joint commission. (2012, June 22). Facts about the national patient safety goals. Retrieved from The joint commission: http://www.jointcommission.org/standards_information/npsgs.aspx Woodard, T.D. (2005). Addressing variation in hospital quality: Is six sigma the answer? Journal of Healthcare Management, 50(4). Retrieved from ACHE: http://www.ache.org/Faculty_Students/student_essay_sample2.pdf