In
establishing its 2010 National Patient Safety Goals
(NPSGs), The Joint Commission — the agency that accredits approximately
17,000 healthcare organizations in the United States — eliminated the
requirement to ensure positive patient identification prior to drawing a
blood sample, despite its stated mission of “… evaluating healthcare
organizations and inspiring them to excel in providing safe and
effective care of the highest quality and value.” The following evidence
seems to indicate that The Joint Commission has placed the needs of the
facilities it inspects above those of their patients.
Exhibit A: The 2009 NPSGs. Obtaining two
identifiers prior to performing a procedure is an established
patient-safety measure, but The Joint Commission still permits both
identifiers to be obtained from a patient’s identification bracelet.
It has been reported, however, that up to 16% of
patients can have ID bands with erroneous information.1
Studies indicate 7% of wristbands are either missing or contain
incorrect information.2 A recent online survey revealed 74%
of respondents have found identification bracelets attached to the wrong
patient.3 What if a patient is wearing a bracelet with
inaccurate information? Misidentified patients can be subjected to
treatments, tests, medications, and transfusions intended for someone
else.
“That’s a problem,” said Margaret Peck, former
director of laboratory accreditation for the agency, when urged by the
Center for Phlebotomy Education to beef up requirements in 2006. This
problem seemed to be resolved with the release of the 2009 NPSGs, which
required active patient involvement (or confirmation from a family
member or caregiver) as a patient identification Element of Performance
(EP). For the first time in the agency’s 100-year history, an ID
bracelet alone could not be considered reliable. With this landmark
provision, the agency’s requirement finally reflected the higher
voluntary standard promulgated by the Clinical and Laboratory Standards
Institute, or CLSI, since at least 1998.
Exhibit B: The 2010 NPSGs. The Joint
Commission stripped the active patient involvement EP from its 2010
goals. Effective in 2010, active patient identification is no longer
required.
Why the deletion of this seemingly simple
patient-safety measure?
Exhibit C: Correspondence between the Center
for Phlebotomy Education and The Joint Commission — which the Center
was given permission to share with its colleagues. “… The deletion of EP
1 is not intended to discourage use of active patient involvement or
minimize its value. However, the requirement as written lacks
enforceability and does not adequately address managing patients who are
not able to participate in the identification process. … When this
requirement is understood by our clients, most find this to be
burdensome and unnecessary.”
Burdensome and unnecessary? Tell that to the family
of Blake Oliver who died in 2007 from a transfusion reaction after his
hospital roommate was drawn for the crossmatch by mistake. Hospital
officials stated, “The error was not a result of the hospital’s failure
to reasonably comply with all applicable statutory and rule
requirements.”4 The error occurred at a time when The Joint
Commission did not require active patient involvement prior to blood
sample collection.
More than 160,000 adverse patient events occur each
year in the United States because of patient or specimen-identification
errors involving the laboratory.5 Studies show that 11% of
transfusion deaths occur as a result of the phlebotomist not properly
identifying the patient or mislabeling the tube of blood.6
One hospital’s audit found that 0.5% of its transfusion specimens were
mislabeled.7
The Joint Commission’s correspondence continues, “…
it was determined that the EP was rendered not surveyable or enforceable
through the accreditation process. This is the reason behind the
deletion. We continue to support active patient involvement in the
identification process as a best practice and will encourage
organizations to use such an approach when it is reasonable to do so.”
Not surveyable? If the The Joint Commission finds it
surveyable to require a patient to be matched to a unit of blood before
transfusion — which it does — why would it not be surveyable to require
a patient to be matched to his ID bracelet before a venipuncture?
Only when The Joint Commission puts the needs of the
patient ahead of the perceived inconveniences of its clients will
patients be protected from mistakes caused by misidentification.
As the industry that provides physicians with 70% of
the objective information on patients’ health, the laboratory community
depends on The Joint Commission to make patient safety a top priority.
Visit
www.jointcommission.org to register
comments on this topic.
References
- Paxton A. Stamping out Specimen Collection
Errors. CAP Today. 1999;13(5):14-16,18. - Howanitz PJ, Renner SW, Walsh MK. Continuous
wristband monitoring over 2 years decreases identification errors: a
College of American Pathologists Q-Tracks study. Arch Pathol Lab
Med. 2002;126:809-815. - Survey Says. Phlebotomy Today-STAT!
November 2009.
www.phlebotomy.com/pt-stat/stat1209.html . Accessed
12/10/09. - State, Bert Fish Hospital Reach Settlement on
Patient Death. Daytona Beach News-Journal.
http://www.news-journalonline.com . Accessed July 16, 2008. - Ford A. Catching ID errors where it counts — in
the lab. CAP Today. 2005;19(9):34-40. - Sauer D, McDonald C, Boshkov L. Errors in
transfusion medicine. Lab Med. 2001;4(32):205-207. - Quillen K, Murphy K. Quality improvement to
decrease specimen mislabeling in transfusion medicine. Arch
Pathol Lab Med. 2006;130:1196-1198.
Dennis J. Ernst, MT(ASCP), is the director of the Center for Phlebotomy Education in Corydon, IN, and a member of the MLO editorial advisory board.
