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A Near Miss Lesson: Check the Wristband
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P E R I O P E R AT I V E GRAND ROUNDS A Near Miss Lesson: Check the Wristband The Case A 28-year-old woman awaiting ambulatory surgery was very anxious about the impending procedure. The patient spoke English and appeared to be of average intelligence. The perioperative nurse who came to the surgical day care unit to meet the patient noted, “I picked up the chart that was next to this patient. It was the correct chart for the patient I was there to meet. I verbally stated the patient’s name, and the woman confirmed her name. She also confirmed other information, including the [type of] surgery.” At the end of the identification procedure, the nurse walked with the patient to the OR and had her positioned on the OR bed. The certified RN anesthetist checked the patient’s wristband and alerted the nurse to an error—the chart the RN had picked up was not for this patient; it had inadvertently been left next to the patient. The nurse stated, “I was shocked. I apolo-
gized and explained to the patient that she was in the wrong room. I had to take the patient off the OR bed and return her to the surgical day care unit.” In retrospect, the nurse realized that she herself had supplied much of the critical information for patient identification, rather than asking the patient open-ended questions and insisting that the patient provide correct identifying information. The nurse realized, “This patient was so anxious she was not actually hearing much of anything I said to her. She agreed with and confirmed whatever I said to her. The error on my part was that I stated her name, and did not check her wristband.“ Luckily, the error was caught and the patient was not harmed. The nurse reported, “I learned a serious lesson, which is to always check the wristband. I now reinforce the importance of checking the wristband with my colleagues whenever I have the opportunity.”
Discussion This is a sobering case of patient misidentification that could have led to wrong-person surgery. As often happens with even serious near-miss and adverse events, this incident involved a confluence of several errors, each of which may seem relatively minor itself: • first, the wrong patient chart was
•
• •
placed by the patient’s bedside; second, the RN did not question whether the chart could be for another patient rather than the person by which it was placed; third, the RN failed to check the patient’s wristband; and fourth, the RN failed to ask patient (continued on page 916)
This content is adapted from Morbidity & Mortality Rounds on the Web, Cases and Commentaries with permission from the Agency for Healthcare Research and Quality (http://www.webmm.ahrq.gov/case.aspx?caseID=22. Accessed October 27, 2008). The original commentary was written by Marilynn M. Rosenthal, PhD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN.
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Perioperative Grand Rounds (continued from page 1096) identification questions in an appropriate manner. As is also often the case, the error was made by a conscientious professional who was remorseful about the error. Today, there is much emphasis on the importance of having a well-informed patient and informed consent, but this case illustrates the difficulties in regarding the patient as the keeper of his or her own safety in the acute care setting. Patient anxiety should be seen as a warning sign that the patient may be unable to participate in the desired manner, which could result in “uninformed consent.”1 Even in the absence of anxiety, patients may respond inaccurately to closed-ended questions (eg, Are you here for arthroscopy today?). Clinicians must take the time to ask patients openended questions (eg, What is your name? What procedure are you having done today?), allowing patients to describe in their own words what they understand to be the treatment they are about to receive or undergo.2,3
In a root cause analysis conducted by the VA National Center for Patient Safety,4 the most common areas where misidentification occurred included the OR, intensive care unit, and cystoscopy room. Patient misidentification rarely appears in incident reports, however. This type of error likely is not seen by front-line workers as reportable or, as in this case, when no harm comes to the patient, it is not deemed to be worth the time to fill out an incident report. There also may be inhibition caused by fear of blame5 or embarrassment because these errors seem so simple to prevent.6 In this case, the perioperative nurse displayed courage and strong ethics by her forthright admission of error to the patient and her willingness to learn from the mistake. However, if all that results is that a single individual vows never to slip up again, the system will remain primed for another error. Health care organizations should encourage the relevant front-line workers to develop solutions that would prevent such errors in the future.
Perioperative Points To avoid a serious misidentification error, perioperative nurses should • use at least two patient-specific identifiers;7 • ask patients open-ended questions about their identity and the procedure they will undergo; • initiate a program of continuous wristband monitoring; • investigate different methods of identification, such as bar coding, electronic patient records,
check lists, and reminder systems; and conduct or participate in routine education• al sessions regarding patient identification. If an adverse or near-miss misidentification does occur, perioperative nurses should • develop a “near miss” reporting mechanism that will track patient care trends and can be analyzed for further error reduction.6 • consider holding regularly scheduled nearmiss reviews.
References 1. Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833. 2. Williams MV. Recognizing and overcoming inadequate health literacy, a barrier to care. Cleve Clin J Med. 2002;69(5):415-418. 3. Williams MV, Davis T, Parker RM, Weiss BD. The role of health literacy in patient-physician communication. Fam Med. 2002;34(5):383-389. 4. NPCS Patient Misidentification Study: a summary of root cause analyses. Topics in Patient Safety. VA National Center for Patient Safety. 2003;(3)1. http://www.patientsafety.gov/TIPS/Docs/TIPS_ Jul03.pdf. Accessed October 26, 2008.
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5. Osborne J, Blais K, Hayes JS. Nurses’ perceptions: when is it a medication error? J Nurs Adm. 1999;29(4):33-38. 6. AORN position statement: Creating a patient safety culture. AORN, Inc. http://www.aorn.org /PracticeResources/AORNPositionStatements/ Position_CreatingaPatientSafetyCulture. Accessed October 26, 2008. 7. 2009 National Patient Safety Goals. Critical Access Hospital Program. Chapter Outline. http://www.jointcommission.org/NR/rdonlyres /4BAD7889-79DE-493F-A6FD-CEB9F003434D/0/ CAH_NPSG.pdf. Accessed October 26, 2008.
P E R I O P E R AT I V E GRAND ROUNDS A Near Miss Lesson: Check the Wristband The Case A 28-year-old woman awaiting ambulatory surgery was very anxious about the impending procedure. The patient spoke English and appeared to be of average intelligence. The perioperative nurse who came to the surgical day care unit to meet the patient noted, “I picked up the chart that was next to this patient. It was the correct chart for the patient I was there to meet. I verbally stated the patient’s name, and the woman confirmed her name. She also confirmed other information, including the [type of] surgery.” At the end of the identification procedure, the nurse walked with the patient to the OR and had her positioned on the OR bed. The certified RN anesthetist checked the patient’s wristband and alerted the nurse to an error—the chart the RN had picked up was not for this patient; it had inadvertently been left next to the patient. The nurse stated, “I was shocked. I apolo-
gized and explained to the patient that she was in the wrong room. I had to take the patient off the OR bed and return her to the surgical day care unit.” In retrospect, the nurse realized that she herself had supplied much of the critical information for patient identification, rather than asking the patient open-ended questions and insisting that the patient provide correct identifying information. The nurse realized, “This patient was so anxious she was not actually hearing much of anything I said to her. She agreed with and confirmed whatever I said to her. The error on my part was that I stated her name, and did not check her wristband.“ Luckily, the error was caught and the patient was not harmed. The nurse reported, “I learned a serious lesson, which is to always check the wristband. I now reinforce the importance of checking the wristband with my colleagues whenever I have the opportunity.”
Discussion This is a sobering case of patient misidentification that could have led to wrong-person surgery. As often happens with even serious near-miss and adverse events, this incident involved a confluence of several errors, each of which may seem relatively minor itself: • first, the wrong patient chart was
•
• •
placed by the patient’s bedside; second, the RN did not question whether the chart could be for another patient rather than the person by which it was placed; third, the RN failed to check the patient’s wristband; and fourth, the RN failed to ask patient (continued on page 916)
This content is adapted from Morbidity & Mortality Rounds on the Web, Cases and Commentaries with permission from the Agency for Healthcare Research and Quality (http://www.webmm.ahrq.gov/case.aspx?caseID=22. Accessed October 27, 2008). The original commentary was written by Marilynn M. Rosenthal, PhD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN.
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AORN JOURNAL • DECEMBER 2008, VOL 88, NO 6
© AORN, Inc, 2008
p1096-916_12_08:Layout 1 11/12/2008 12:18 PM Page 916
Perioperative Grand Rounds
DECEMBER 2008, VOL 88, NO 6
Perioperative Grand Rounds (continued from page 1096) identification questions in an appropriate manner. As is also often the case, the error was made by a conscientious professional who was remorseful about the error. Today, there is much emphasis on the importance of having a well-informed patient and informed consent, but this case illustrates the difficulties in regarding the patient as the keeper of his or her own safety in the acute care setting. Patient anxiety should be seen as a warning sign that the patient may be unable to participate in the desired manner, which could result in “uninformed consent.”1 Even in the absence of anxiety, patients may respond inaccurately to closed-ended questions (eg, Are you here for arthroscopy today?). Clinicians must take the time to ask patients openended questions (eg, What is your name? What procedure are you having done today?), allowing patients to describe in their own words what they understand to be the treatment they are about to receive or undergo.2,3
In a root cause analysis conducted by the VA National Center for Patient Safety,4 the most common areas where misidentification occurred included the OR, intensive care unit, and cystoscopy room. Patient misidentification rarely appears in incident reports, however. This type of error likely is not seen by front-line workers as reportable or, as in this case, when no harm comes to the patient, it is not deemed to be worth the time to fill out an incident report. There also may be inhibition caused by fear of blame5 or embarrassment because these errors seem so simple to prevent.6 In this case, the perioperative nurse displayed courage and strong ethics by her forthright admission of error to the patient and her willingness to learn from the mistake. However, if all that results is that a single individual vows never to slip up again, the system will remain primed for another error. Health care organizations should encourage the relevant front-line workers to develop solutions that would prevent such errors in the future.
Perioperative Points To avoid a serious misidentification error, perioperative nurses should • use at least two patient-specific identifiers;7 • ask patients open-ended questions about their identity and the procedure they will undergo; • initiate a program of continuous wristband monitoring; • investigate different methods of identification, such as bar coding, electronic patient records,
check lists, and reminder systems; and conduct or participate in routine education• al sessions regarding patient identification. If an adverse or near-miss misidentification does occur, perioperative nurses should • develop a “near miss” reporting mechanism that will track patient care trends and can be analyzed for further error reduction.6 • consider holding regularly scheduled nearmiss reviews.
References 1. Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833. 2. Williams MV. Recognizing and overcoming inadequate health literacy, a barrier to care. Cleve Clin J Med. 2002;69(5):415-418. 3. Williams MV, Davis T, Parker RM, Weiss BD. The role of health literacy in patient-physician communication. Fam Med. 2002;34(5):383-389. 4. NPCS Patient Misidentification Study: a summary of root cause analyses. Topics in Patient Safety. VA National Center for Patient Safety. 2003;(3)1. http://www.patientsafety.gov/TIPS/Docs/TIPS_ Jul03.pdf. Accessed October 26, 2008.
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5. Osborne J, Blais K, Hayes JS. Nurses’ perceptions: when is it a medication error? J Nurs Adm. 1999;29(4):33-38. 6. AORN position statement: Creating a patient safety culture. AORN, Inc. http://www.aorn.org /PracticeResources/AORNPositionStatements/ Position_CreatingaPatientSafetyCulture. Accessed October 26, 2008. 7. 2009 National Patient Safety Goals. Critical Access Hospital Program. Chapter Outline. http://www.jointcommission.org/NR/rdonlyres /4BAD7889-79DE-493F-A6FD-CEB9F003434D/0/ CAH_NPSG.pdf. Accessed October 26, 2008.