title: An intervention to decrease patient identification band errors in a children's hospital.
abstract: BACKGROUND
  Patient misidentification continues to be a quality and safety issue. There is a paucity of US data describing interventions to reduce identification band error rates.
  
  
  METHODS
  Monroe Carell Jr Children's Hospital at Vanderbilt.
  
  
  METHODS
  Percentage of patients with defective identification bands.
  
  
  METHODS
  Web-based surveys were sent, asking hospital personnel to anonymously identify perceived barriers to reaching zero defects with identification bands. Corrective action plans were created and implemented with ideas from leadership, front-line staff and the online survey. Data from unannounced audits of patient identification bands were plotted on statistical process control charts and shared monthly with staff. All hospital personnel were expected to "stop the line" if there were any patient identification questions.
  
  
  RESULTS
  The first audit showed a defect rate of 20.4%. The original mean defect rate was 6.5%. After interventions and education, the new mean defect rate was 2.6%.
  
  
  CONCLUSIONS
  (a) The initial rate of patient identification band errors in the hospital was higher than expected. (b) The action resulting in most significant improvement was staff awareness of the problem, with clear expectations to immediately stop the line if a patient identification error was present. (c) Staff surveys are an excellent source of suggestions for combating patient identification issues. (d) Continued audit and data collection is necessary for sustainable staff focus and continued improvement. (e) Statistical process control charts are both an effective method to track results and an easily understood tool for sharing data with staff.
authors.affiliation: Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee 37232-9750, USA. paul.hain@vanderbilt.edu
authors.forename: Paul D
authors.initials: PD
authors.lastname: Hain
authors.forename: B
authors.initials: B
authors.lastname: Joers
authors.forename: M
authors.initials: M
authors.lastname: Rush
authors.forename: J
authors.initials: J
authors.lastname: Slayton
authors.forename: P
authors.initials: P
authors.lastname: Throop
authors.forename: S
authors.initials: S
authors.lastname: Hoagg
authors.forename: L
authors.initials: L
authors.lastname: Allen
authors.forename: J
authors.initials: J
authors.lastname: Grantham
authors.forename: J K
authors.initials: JK
authors.lastname: Deshpande
mesh_terms: D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D008485:Medical Audit; D019300:Medical Errors / Q000517:prevention & control*; D010355:Patient Identification Systems / Q000592:standards*; D011785:Quality Assurance, Health Care; D013714:Tennessee