title: Reduction in pediatric identification band errors: a quality collaborative.
abstract: OBJECTIVE
  Accurate and consistent placement of a patient identification (ID) band is used in health care to reduce errors associated with patient misidentification. Multiple safety organizations have devoted time and energy to improving patient ID, but no multicenter improvement collaboratives have shown scalability of previously successful interventions. We hoped to reduce by half the pediatric patient ID band error rate, defined as absent, illegible, or inaccurate ID band, across a quality improvement learning collaborative of hospitals in 1 year.
  
  
  METHODS
  On the basis of a previously successful single-site intervention, we conducted a self-selected 6-site collaborative to reduce ID band errors in heterogeneous pediatric hospital settings. The collaborative had 3 phases: preparatory work and employee survey of current practice and barriers, data collection (ID band failure rate), and intervention driven by data and collaborative learning to accelerate change.
  
  
  RESULTS
  The collaborative audited 11377 patients for ID band errors between September 2009 and September 2010. The ID band failure rate decreased from 17% to 4.1% (77% relative reduction). Interventions including education of frontline staff regarding correct ID bands as a safety strategy; a change to softer ID bands, including "luggage tag" type ID bands for some patients; and partnering with families and patients through education were applied at all institutions.
  
  
  CONCLUSIONS
  Over 13 months, a collaborative of pediatric institutions significantly reduced the ID band failure rate. This quality improvement learning collaborative demonstrates that safety improvements tested in a single institution can be disseminated to improve quality of care across large populations of children.
authors.affiliation: Cleveland Clinic Children’s Hospital, Cleveland, Ohio 44195, USA. phillis@ccf.org
authors.forename: Shannon Connor
authors.initials: SC
authors.lastname: Phillips
authors.forename: Michele
authors.initials: M
authors.lastname: Saysana
authors.forename: Sarah
authors.initials: S
authors.lastname: Worley
authors.forename: Paul D
authors.initials: PD
authors.lastname: Hain
mesh_terms: D015331:Cohort Studies; D003299:Cooperative Behavior; D003625:Data Collection / Q000379:methods; D005500:Follow-Up Studies; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control* / Q000639:trends; D010348:Patient Care Team / Q000592:standards* / Q000639:trends; D010355:Patient Identification Systems / Q000379:methods / Q000592:standards* / Q000639:trends; D011785:Quality Assurance, Health Care / Q000379:methods / Q000592:standards / Q000639:trends