Monday, March 19, 2012

Are you Mrs. Smith? Well, it doesn't really matter to me.

It is so simple and so important:  Identifying a patient before administering medications, taking vital signs, extracting blood, or engaging in other care procedures.  But this new article by Etienne Phipps and others suggests that it just doesn't happen the way it should.  The abstract says:

Findings:  Although residents and nurses viewed PT ID as crucial to patient safety, they cited time pressures; confidence in their ability to informally identify patients; and a desire to deliver personal, humanistic care as reasons for not consistently verifying patient identification. Nurses expressed concern about annoying, offending, and/or alienating patients by repeatedly checking wristbands and asking date of birth, in the belief that excessive patient identification practices could undermine trust. Residents relied on nurses to check ID and preferred to greet the patient by name, a practice that they viewed as more consistent with their professional identity. Referring to patients by their room number and location was cited as a commonly used practice of PT ID and a contributor to errors in identification.

Conclusions:  Nurses and residents are aware of the importance and requirements to verify PT ID, but their adherence is mitigated by a variety of factors, including assessment of necessity or risk, impact on their relationship with the patient, and practices in place in the hospital environment that protect patient privacy. 

Oh, please tell me this isn't so. This is the simplest of all safety measures.  These are terrible excuses for non-compliance.

I remember one day when I was CEO of the hospital, and I had to have some blood drawn. The tech, knowing who I was, used the opportunity to talk to me for ten minutes about hospital-related issues and then said, "OK, it is time to draw some blood.  What is your name?  What is your birth date?"  I congratulated her for following the proper procedure.


e-Patient Dave said...

Last fall Peter Margolis at Children's in Cincinnati presented a slide that Susannah Fox reported later:

.5 x .5 = .25

Providers do what they're supposed to about half the time; patients do what they're supposed to half the time. Together, we achieve about 25% of what we already know how to do.

I've recently been reading about behavioral economics and other psychological aspects of the breakdown between intent and action. (Mostly people write about this as a patient issue, where they call it "compliance," but clearly it's a provider issue too, although there it's called "quality"! So I'm glad this article says "their adherence" and you call it non-compliance.)

That research strongly suggests that even a well trained mind is prey to illusions and odd breakdowns.

So I increasingly see this not as "excuses" for non-compliance, but as windows into the illusions that lead well meaning, well trained people to do the wrong thing time after time after time. I fervently hope we'll figure out how to re-engineer the issues so we don't depend so much on the reliability of a demonstrably unreliable mechanism - the link between training and intent. It's not just a matter of good intentions - the research has convinced me those failings aren't just a failure of will.

(The big book I read about it, fat and full of chewy research over 30 years, Thinking, Fast and Slow by Nobel economist Daniel Kahneman; I'm halfway through listening to the much lighter and user-friendly Switch, which seems to make exactly the same points, quite precisely. Switch alone couldn't give me confidence that comes from the deep, solid foundation that Kahneman provides, but having read the big one, I get it.)

People still need to be responsible for sticking to the protocol but increasingly I see the need for us to provide environments and tools that make it much much easier to do the right thing. I no longer do nearly as much blamecasting as I used to, because I see the evidence that (perversely) things aren't under as much conscious control as we have thought.

That doesn't relieve responsibility! It just points the solutions searchlight in a different direction.

Anonymous said...

Dave, I understand your comment but patient ID often falls under the rubric of 'unintentionally intentional' lack of compliance with protocols. As with Paul's example, it is so easy to say "I know who that patient is, so why use this stupid protocol?"

As a former medical lab and blood bank director, I could use the 50 ways to leave your lover analogy to describe all the ways I have seen patient ID screwed up, with sometimes fatal consequences. For instance, this is by far the most common way to die immediately from a blood transfusion. There is a reason for these protocols and, indeed, no 'excuse' for not following them.

Many thanks for Paul for highlighting this absolutely critical issue.

nonlocal MD

Julia Kent said...

I agree that we need to follow proper procedures here, but I do wonder how many errors are actually made with PT ID statistically speaking? I guess such figures would never be available, so we'll never know.

Love your blog by the way

Anonymous said...

Julia, I couldn't turn down your challenge. Global numbers for patient ID errors are indeed difficult to find, as there are numerous components to ID errors which are studied separately. In addition, it is known that errors not resulting in harm to the patient are usually not reported at all, thus there is significant under-reporting. However, the quote below may give you a taste:

"Research by the Joint Commission published in 2005 discovered that patient identification errors were at fault for 13 percent of surgical mistakes and 67 percent of transfusion mix-ups – amounting to tens of thousands of incidents each year."

This is by no means a rare event, and fatalities are not rare either.

nonlocal MD

Anonymous said...

Also true that as patients we get impatient with repeating ourselves, wonder if anyone is paying any attention at all, and feel perpetually impersonalized in a system that's pretty impersonal especially after a few days in. I don't mind being asked before a procedure, but I'm part of the system. Add in a safety comment (Just to be safe, before we start, what's your name and DOB?)and I expect very few patients would feel less trust. Both sides probably understand less than we would like to believe about what the other side is doing/thinking (thanks Dave for the math!) so let patients know its all about keeping them safe.

Anonymous said...

Building on the previous comment, I think I would feel very scared as a patient if every time anyone came to see me they asked my name and DOB. I would begin to wonder why this information wasn't in my chart, or if the person had even looked at my chart. I suppose a big sign at the headrest with my name and DOB would violate patient confidentiality, but at least then it could be referenced. "I see from the sign your name is Paul, correct?" vs "The chart says you have been here 9 days... What's your name?"

Anonymous said...

In a recent hospital stay, I noticed that the staff always asked my name before any procedure, regardless of how minor. As a regular reader of this blog, I understood (and appreciated!) why they did that and had no trouble cooperating.

A year or two ago, I might not have understood and eventually gotten snippy with what (at first glance) seems to be monotonous or silly behavior by the care givers.

If I had, hopefully the nurse would have had a ready explanation for why this was done. Even better - an up-front explanation during the admissions process (where feasible) might help patients understand and appreciate the care being taken.