Running head: PATIENT MISIDENTIFICATION

Safety Performance Improvement: Patient Misidentification

Meeker Group One

Old Dominion University

PATIENT MISIDENTIFICATION 2

Safety Performance Improvement: Patient Misidentification

Patient safety is an essential element to providing high-quality health care and is defined

as the absence of preventable harm to a patient and reduction of risk of unnecessary harm

associated with health care to an acceptable minimum (Patient Safety, 2015). Effectively

identifying patients and accurately matching the appropriate treatment or procedure is crucial to

maintaining patient safety. Patient identification strategies to avoid patient safety errors and to

improve health care processes have been outlined by The Joint Commission (TJC). In order to

avoid incidents of misidentification, near-misses, or potential adverse events, TJC requires that

two identifiers such as a patient’s full name, date of birth and/or medical identification number

be used for every patient encounter (The Joint Commission, 2014). Failure to match the right

patient with their appropriate service or treatment is referred to as “wrong-patient errors”.

Wrong-patient errors due to misidentification are a widespread occurrence that have

harmful and sometimes fatal outcomes (Preventable, 2016). Patient misidentification may lead

to errors in medication administration, failure to treat serious illness, procedures performed on

the wrong patient, and unnecessary treatment due to erroneous diagnostic lab results

(Preventable, 2016). To identify and determine the types of issues involving misidentifications

in facilities, a patient safety report from the nonprofit research group, The ECRI Institute,

examined errors and near-misses. Healthcare organizations from January 2013 to July 2015, the

ECRI report examined 7,613 wrong-patient events submitted by 181 healthcare organizations

(Preventable, 2016). The majority of wrong-patient events occurred during diagnostic

procedures 2,824 or 36.5% (Preventable, 2016). Diagnostic procedures may include laboratory

medicine, pathology, and diagnostic imaging (Preventable, 2016). An example of diagnostic

errors includes errors in specimen labeling. Specimen labeling errors have been identified as
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dangerous and affect the quality of care provided to patients; therefore, identification standards

and goals have been put in place to help address the issue. Misidentification can lead to patients

being diagnosed and treated and their conditions managed based on the laboratory results from

other patients. For this reason, patient identification and correct labeling are the most important

tasks not only in the testing process but in all areas of health care. The purpose of this paper is to

examine wrong-patient events present in lab specimen collection techniques associated with

inadequate patient ID collection processes, discuss patient impact and explore opportunities for

improvement to improve safety and promote positive patient outcomes.

Plan for Data Analysis and Change

The problem of mislabeling of lab specimens during venipuncture in the emergency

department (ED), as a result of a failure to verify at least two patient identifiers, is a serious

safety issue that needs to be addressed. There are three phases of the lab testing process, pre-

analytical, analytical and post-analytical (Hammerling, 2012). The pre-analytical stage is the

time that elapses between the blood draw and the processing of the specimen. The analytical

phase is from the beginning of the processing phase until the results are interpreted. The post-

analytical phase occurs when the results are interpreted through the time they are released to the

medical provider. The majority of errors tend to occur in the pre-and post-analytical phases due

to technological and quality control improvements in the specificity of equipment utilized in the

analytical phase (Hammerling, 2012). Pre-analytical errors happen as a result of human

error. Errors like this occur all too often for any number of reasons, especially in a busy ED. In

one study the ED accounted for only 20% of the overall labs for the hospital, and it had 41% of

the patient identification errors (Ning et al., 2016). In a large multicenter study, 55.5% of patient

identification errors were reported to be associated with primary specimen labeling errors (Ning
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et al., 2016). It is also estimated that 1 in 18 patient identification errors result in adverse events

and the cost of misidentified specimens is estimated to be around $280,000 per million

specimens (Ning et al., 2016). Interventions to ensure proper patient identification prior to

obtaining lab work from a patient can be technical and non-technical in nature. Some examples

of more technical interventions are scanning barcodes or more advanced methods of radio

frequency identification, biometrics, magnetic stripes, optical character recognition, smart cards,

and voice recognition devices (Agarwal, 2014). One of the major disadvantages of technical

interventions is the cost, therefore it was determined that a more non-technical methodology

would be utilized initially to address the problem.

Once the problem has been identified, the unit manager or administrator will then collect

the data from the lab, patients’ charts, discharge surveys and formal complaints made by patients

and/or their families. Once the data is collected, the managers identify all possible strategies and

solutions to improve the issue and build a case for the new process. One way to plan change is to

hold a faculty meeting, explain the current issue, in this case, mislabeling of labs, and identify

what needs to be changed. It is important to present current attitudes, habits, and ways of

thinking to the staff in a way that softens the idea of change, so members involved are prepared

for new ways of thinking and behaving. During this meeting, information is provided from the

data collected and analyzed regarding the frequency of patient misidentification, specifically

mislabeling lab work, within the facility. This is when the new proposal is presented, making it

clear that it is not something that will change overnight, but gradually over a month span.

Managers will make sure staffing and additional resources are adequate for this new change to

help reduce anxiety. Control points will be established with the shift charge nurses who will

provide the feedback to help evaluate the progress.

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Identifying Supporters, Opposers, and Strategies to Unify Supporters

A critical gap has been identified and a safety change will be implemented. Although, the

inevitable change variable is not favored by most stakeholders in the organization. A proposed

change is sometimes required to enable organizations to adapt and grow in the areas they service.

When a change is planned, it can become a source of disagreement and can promote resistance

among those affected by change. This source of conflict can create a difficult working

environment. Even when change is planned and expected, a grief reaction can occur (Sullivan,

2018). As nurses, we accept that the healthcare field is constantly evolving to meet the needs of

a large population, technological advancements and industry medical coverage practices. Nurses

are more amenable to accepting change with an open mind because we understand that our

patient populations are directly affected by the inherent outcomes of change.

Change is predominantly implemented by key personnel and executed by the workforce.

It is important to have key players and policy makers interested in innovation and their

commitment to making change happen (Sullivan, 2018). Senior administrators of an

organization must be on board with change and be a part of the group that will encompass the

main supporters of change. When there is a lack of support from the top, opposition will

inevitably be emboldened and chances are that the initiative will flounder. There are so many

unknowns regarding the predictive analysis of impending change. Hospital leadership, medical

professionals and patients are all possible beneficiaries of change. Although, these same groups

might suffer negative second order effects of a change. The best course of action is to understand

the potential outcomes, educate the affected populations and ensure transparency throughout the

implementation of organizational change.

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Key supporters of an organization should be excited about the change and enthusiastic

about the possible outcomes. This enthusiasm can be a driving force in the success behind

change (Sullivan, 2018). Alternatively, leadership who are averse to change should think about

leaving the organization or transferring to a section not affected by the change (Sullivan, 2018).

One toxic leader can spoil the process and hinder the growth of an entire organization, resulting

in reduced capacity to provide the best care for our patients.

A strategy focused on building a coalition to encourage change includes a variety of

involvement activities. According to a literature review conducted, the findings included six

guiding principles: aligning vision and action of the plan, make small changes with a

transformation strategy, foster distributed leadership, promote staff engagement, create

relationships that allow collaboration and finally continuous assessment of organizational culture

(Willis et al., 2016). The staff is the front-line personnel directly involved with executing change

in their practice and with their patients. Strategies identified in this literature review included;

focus groups, unit-level improvement teams, brainstorming sessions, completion of small-scale

projects, on-site visits, teleconferences and individual consultations of practice (Willis et al.,

2016). It is important to engage leaders and frontline staff during change implementation by

encouraging participation through incentive strategies, such as pay for performance, specific

training opportunities, public recognition or even workplace social events (Willis et al., 2016).

Cross communication is important as leadership talks as well as eliciting input from the

workforce and the workforce talks to patients.

Change Theory

The change theory developed by John Kotter was selected to be the most appropriate,

considering the potentially fatal implications with the two patient identifier safety issues.
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Kotter’s theory of change begins by determining a sense of urgency which was substantiated by

the improper diagnosis and treatment and resulting patient deterioration resulting from the

mislabeling of specimen tubes due to lack of verifying two patient identifiers (Sullivan, 2018).

The next step in Kotter’s theory is to form a powerful coalition of health care staff with

representation from all departments involved in the collection of patient lab specimens (Sullivan,

2018). An ad hoc committee is formed with the representatives providing input regarding

driving and restraining forces contributing to the problem. Identification of issues preventing the

staff from performing the two-patient identifier assessment process may be a missing arm band,

pre-labeled specimen containers that were not verified or patient identifiers provided by the

hospital staff with the expectation of a yes/no answer from the patient.

By identifying all contributing factors ad hoc members are able to visualize the positive

impact of changes made and how they will eliminate future problems (Sullivan, 2018). The first

step of change is to evaluate the current policies and procedures and determine if the steps in the

process apply to current lab specimen retrieval practices in the institution. Once the process is

determined to be current and applicable, all staff must be trained or re-trained on all of the steps

in the patient identifier verification process. For instance, the staff member verifies the patient’s

complete name and date of birth with the name and date of birth associated with the order placed,

followed by verifying the arm band and the labels printed prior to applying them to the specimen

container and before performing the blood draw. Once the blood is drawn the labels are

immediately placed on the tubes at the patient’s bedside.

Communicate the vision to staff at a called staff meeting specifically for the purpose of

discussing the mandatory training required regarding proper patient identification prior to

obtaining a lab specimen (Sullivan, 2018). Review the steps while providing a demonstration to
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staff, incorporating clues to improper adherence to process, such as a missing armband or asking

yes/no questions, so that staff may point out errors in the process.

Empower staff to act by requiring staff to observe and document the observation of one

another performing the process of obtaining a lab specimen from patients, a specified number of

times (Sullivan, 2018). As the observations occur, documentation should be returned to the unit

manager by a specified date to ensure that all staff have met the required number of observations.

This will place the responsibility of ensuring proper training on all staff members. Staff should

be encouraged to report short term wins or near misses as they are identified, such as a missing

armband, inconsistent information in the electronic health record vs. patient verbal verification,

or observation by another staff member of the process not being followed.

The above examples of steps in the lab specimen acquisition process should be tested for

a specified length of time while data is collected, such as the number of total labs drawn, the

number of improperly labeled lab work and the circumstances, the number of near misses

identified and the circumstances and the amount of time required to follow the process, for

example. Once the test of change is complete the ad hoc committee reconvenes to analyze the

data collected during the change to ensure that the proposed change effectively addresses all

driving and restraining forces initially determined. Then a plan is developed to institutionalize

the change, by adapting the procedure to the new process, determined effective by the test of

change and is then spread throughout the organization (Sullivan, 2018). Ensure continued

adherence to the procedure by evaluating staff as a part of their annual performance metrics.

Resistance to the Proposed Change and Strategies to Manage Resistance

Misidentifying patients and the potential harm occurs every day nationwide (Probst et al.,

2016). Processes put in place to reduce misidentification of patients will face some form of
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resistance. Robert Kennedy in a speech on May 6, 1964 stated, one-fifth of the people are against

everything all of the time. Resistance to change in the patient identification process comes as a

result of staff feeling comfortable with the current practice, fear of the unknown and how the

change process will affect their current practice. Anticipated resistance to change, will be a

reluctance to comply with any form of change to the current way of identifying patients. Staff

might not do what the change process directs them to do. Staff may resist by arguing and look

for fault in the change process. They may also resist by reverting back to their old ways. The

change process might be delayed by staff agreeing to undergo the change but not actually

implementing the change. There may be a negative attitude towards the change process

extending from an adverse response from an external place. This may result from the spread of

negative information about the change process (Lines et al., 2015). Education is the key to

manage resistance to change. The right education at the right time goes a long way to reduce

resistance. Care should be taken when educating staff. Different educational strategies should be

explored.

In the article, “Educational Strategies to Improve Adherence to Patient Identification”

(2015), it was noted that healthcare staff improved their compliance in verifying patients’

wristband before providing care, and this resulted from different educational strategies being

used (Hemesath et al., 2015). Another method to manage resistance to change is to appoint a

change agent, who is tasked with follow up of the change process. Change agents are responsible

for incorporating change into practice. They also provide clarification to the change process in

case there is any confusion. Research indicates that organizations without a change agent had

four times more resistance to change than organizations with change agents (Lines et al., 2015).
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Feedback Mechanism and the Evaluation Process

In order to evaluate the processes put in place to improve patient identification, the

number of issues, errors or harm incurred as a result of patient misidentification must be

collected and analyzed to evaluate the change process. A measurable outcome to evaluate the

success of the change process is a reduction in errors or issues arising from misidentification

following the month long educational and implementation process. As noted by Prade Hemesath

et al (2015), education is the most effective means to improve adherence to patient ID

verification by health professionals. Before the educational process, a staff needs assessment

will be done by a means of survey. The needs assessment survey will provide the basis for the

educational program. This will permit the teacher to tailor the education program based on the

staff’s learning preferences through in-services. After a month following education of the staff

on the importance of proper identification, data from patient misidentification will be collected

and compared to months prior to staff education. The data will reveal if the education resulted in

a decrease in patient misidentification.

Stabilizing the Change

Once the plan for decreasing the mislabeling of lab specimens during venipuncture in the

ED has been tested, analyzed, and implemented in the department, next comes the time to plan

stabilization of the change. Ongoing monitoring and evaluation may be key for reinforcing

positive behaviors and preventing harm (Boroyan, 2016). It is not uncommon for staff to fall

back to their old ways, so it is important for frequent reminders to be implemented into the

everyday workflow of the unit. Signs can be posted at computer workstations reminding staff to

check two patient identifiers prior to sending lab specimens. Ongoing staff education can be

provided at regular staff meetings and yearly with their annual performance evaluations.
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Leadership’s Role

A leader is defined as anyone who uses personal behaviors and strategies to encourage

others to reach a specific goal (Sullivan, 2018). A leader does not necessarily have to be a

manager, but because managers play a vital role in implementing change, all good managers

should be good leaders. Part of a manager’s responsibility is to efficiently accomplish goals of

the organization (Sullivan, 2018). In a study done to investigate nurse managers’ accounts of

organizational change it was found that effective communicators were central to their approach

to managing change and that more attention to work‐based learning and support assists managers

in their role (Hewison, 2012). This can be facilitated by selecting a couple of staff members that

perform venipuncture to be trained as experts by providing additional reinforcement by

reminding staff to double check patient identification prior to sending labs for processing. These

same staff members will also perform periodic safety checks to reinforce this behavior.

Conclusion

Decreasing adverse events as a result of proper verification of patient identifiers is one of

the most avoidable patient safety issues in healthcare. Misidentification during the pre-analytical

phase of blood specimen collection in the emergency room is an area where errors frequently

occur. This research paper substantiates the need for performance improvement activities, such

as implementation of a test of change supported by a change theory, identification of support and

resistance to change and how to succeed, the role of leadership and ways to sustain change

through ongoing monitoring and evaluation.

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References

Agarwal, R. (2014). Quality- improvement measures as effective ways of preventing laboratory

errors. Lab Medicine, 45(2), Pages e80-e88,

https://doi.org/10.1309/LMD0YIFPTOWZONAD

Boroyan, N. (2016). ECRI: "Most if not all" patient identification errors preventable. Retrieved

from https://healthitanalytics.com/news/ecri- most- if- not-all-patient- identification-errors-

preventable

Hammerling, J. (2012). A review of medical errors in laboratory diagnostics and where we

are today. Lab Medicine, 43(2), Pages 41-44,

https://doi.org/10.1309/LM6ER9WJR1IHQAUY

Hemesath, M., Barreto Dos Santos, H., Torelly, E., Da Silveira Barbosa, A. & Müller de

Magalhães, A. (2015). Educational strategies to improve adherence to patient

identification. Revista Gaúcha De Enfermagem, 36(4), 43-48.

Hewison, A. (2012). Nurse managers’ narratives of organizational change in the english national

health service. Journal of Nursing Management,20(7), 858-867. doi:10.1111/j.1365-

2834.2012.01359.x

Lines, Sullivan, Smithwick, & Mischung. (2015). Overcoming resistance to change in

engineering and construction: Change management factors for owner

organizations. International Journal of Project Management, 33(5), 1170-1179.

Ning HC, Lin CN, Chiu DTY, Chang YT, Wen CN (2016). Reduction in hospital-wide clinical

laboratory specimen identification errors following process interventions: A 10-year

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retrospective observational study. PLUS ONE, 11(8), e0160821.

http://doi.org/10.1371/journal.pone.0160821

Patient Safety. (2015). Retrieved from http://www.who.int/patientsafety/about/en/

Preventable, potentially fatal patient identification errors analyzed by ECRI institute. (2016).

Surgical Products, Retrieved from http://proxy.lib.odu.edu/login?url=https://search-

proquest-com.proxy.lib.odu.edu/docview/1823653422?accountid=12967

Probst, C., Wolf, L., Bollini, M., & Xiao, Y. (2016). Human factors engineering approaches to

patient identification armband design. Applied Ergonomics, 52, 1.

Sullivan, E. (2018). Effective leadership and management in nursing (9th ed). Boston, MA:

Pearson Education.

The Joint Commission, (2014). National Patient Safety Goals. Retrieved from.

www.jointcommission.org

Willis, C. D., Saul, J., Bevan, H., Scheirer, M. A., Best, A., Greenhalgh, T., & ... Bitz, J. (2016).

Sustaining organizational culture change in health systems. Journal Of Health

Organization & Management, 30(1), 2-30. doi:10.1108/JHOM-07-2014-011

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Honor Code:

I pledge to support the Honor System of Old Dominion University. I will refrain from any form

of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a

member of the academic community it is my responsibility to turn in all suspected violations of

the Honor Code. I will report to a hearing if summoned.

Electronic signature: Natasha Willis, Diane Thomas, Lyzette Terman, Dagny Thorsen, Godwill

Tomlah, Jennifer Tyler 07/15/18

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Criteria Exemplary Accomplished Developing Beginning Total

14-15 points 12-14 points 11-13 points 0-10 points /15

Identify a TJC The goal is clearly The goal is The goal is weak or
safety goal that The goal is
comprehensive, stated and unclear and is too absent. The
is relevant to an
somewhat broadly or too situation that
area of concern clearly stated, and
at your place of focused. The narrowly needs change is
focused. The
employment or situation that focused. The poorly or
situation that
clinical
needs change is needs change is situation that incompletely
rotations. described and needs change is described with
Describe a clearly described
includes relevant described with little or no data
situation that and includes
needs change. relevant data. data. some data that that relates to the
Identify data relates to the problem.
related to the problem.
problem to be
collected.

12-14 points 11-13 points 0-10 points /15

14-15 points
Develop a plan
for data
analysis and All components for Most components Limited Minimal or no
plan for change,
including time developing a plan for developing a components for components for
frame and for analysis and plan for analysis developing a plan developing a plan
resources. change are and change are for analysis and for analysis and
thoroughly and completely change are change are
completely addressed. addressed. Ideas addressed. Ideas
addressed. expressed are expressed lack
general in nature depth, are off-
and/or topic and/or
occasionally may confusing to
not be relevant. follow.

9-10 points 7-8 points 5-6 points 0-4 points /10

Identify
potential Thorough and Adequate Some limited Minimal or very
supporters and
opposers and complete discussion of discussion of limited discussion
strategies to discussion of Potential Potential of Potential
build a coalition Potential supporters and supporters and supporters and
of supporters. supporters and opposers. opposers. opposers.
opposers.
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All components for Most components Limited Minimal or no /10

Using an utilizing an for utilizing an components for components for
appropriate
change model
appropriate appropriate utilizing an utilizing an
or theory, change model or change model or appropriate appropriate
describe how theory are theory are change model or change model or
this model or thoroughly and addressed. theory are theory are
theory could be completely addressed. Ideas addressed. Ideas
used to prepare addressed. expressed are expressed lack
for change and
to implement general in nature depth, are off-
the change and/or topic and/or
process. occasionally may confusing to
not be relevant. follow.

9-10 points 7-8 points 5-6 points 0-4 points

Describe Anticipated Anticipated Anticipated Anticipated /10

anticipated resistance and resistance and resistance and resistance and
resistance to
the proposed strategies for strategies for strategies for strategies for
change and management are management are management are management are
strategies to thoroughly and addressed. general in nature minimally
manage completely and may or may discussed,
resistance. addressed. not be relevant. irrelevant, or not
discussed.

9-10 points 7-8 points 5-6 points 0-4 points

Describe All criteria Most criteria Limited Minimal /10

feedback addressed. addressed. components of or no criteria
mechanisms
and the
Thorough, logical, There is adequate criteria addressed.
evaluation and clear discussion of addressed. There Minimal
process discussion of measurable is some general discussion of
including measurable outcomes discussion of outcomes.
measurable outcomes described. outcomes. Outcomes may
outcomes.
described. not measurable.

9-10 points 7-8 points 5-6 points 0-4 points

Discuss a brief Thorough and Adequate Some but limited Minimal or very /5
plan for complete discussion of plan discussion of plan limited discussion
stabilizing the
change. discussion of plan for stabilizing the for stabilizing the of plan for
for stabilizing the change. change. stabilizing the
change. change.

5 points 4-5 points 3-4 points 0-2 points

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Briefly describe Thorough and Adequate Some but limited Minimal or very /5
leadership’s
complete discussion of discussion of limited discussion
role in this PI
process. Identif discussion of leadership’s role. leadership’s role. of leadership’s
y key players leadership’s role. Key players Some general role. Minimal or
who would be Key players identified. discussion of key no discussion of
beneficial for identified. players. key players.
success.
5 points 4-5 points 3-4 points 0-2 points
Writing Quality, Posts show above Posts show Posts show an Posts show a /10
Grammar & APA average writing average writing average and/or below
style using style using casual writing average/poor
standard English, standard English style with some writing style in
basically free from with few grammar, errors in spelling, terms of
grammar, punctuation, and grammar, appropriate
punctuation, and spelling errors. punctuation, and standard English
spelling errors. 0-1 2-3 APA errors. usage. 4-5 APA writing style,
APA errors. errors. clarity, language
used, and
grammar. >5 APA
errors.

9-10 points 7-9 points 5-6 points 0-4 points

9-10 points 7-9 points 5-6 points 0-4 points

Include 4 references 3-4 references Less than 3 /10

minimum 4 4 or more
references included. included. references
textbook or
Literature Literature for included.
journal articles included.
as references. supports supporting Literature for
Literature clearly
Include a copy supports adequate discussion is supporting
of rubric and discussion. general. discussion is weak
discussion.
Honor Code. or not relevant.
Submit through
Safe Assign.

TOTAL POINTS (sum of all criteria) /100