[Counter-measures against patient misidentification and specimen mismanagement with blood collection]

My theme for this symposium is counter-measures against patient misidentification and specimen mismanagement with blood collection due to the lack of using authentication systems. What is applicable to our laboratory is patient misidentification counter-measures for specimen management at the time of inpatient ward blood collection and specimen examination (mistakes in appending bar code labels and entering specimen numbers). During the period from January 2008 to July 2012 at our laboratory, there were 9 cases of patient misidentification for hospital ward blood collection and specimen management. There were 2 cases in 2008 (1 for blood collection, 1 for specimen management), no cases in 2009, 3 cases in 2010 involving blood collection, 1 case in 2011 involving specimen management, and 3 cases in 2012 (1 for blood collection, 2 for specimen management). All patient misidentifications involving hospital ward blood collection arose from bedside blood collection. As a counter-measure, training slides were created at a medical safety management review session, repeated training in attention and patient check procedures was conducted with staff members, and hands-on training in pointing and naming was carried out. With these training slides, the goal was the execution of verification duties by encouraging conversations that include the patient's name, such as "Mr./Ms. XXXX, today we'll be collecting 3 tubes of blood," as a link to patient verification duties. With specimen management, 3 of the 4 cases occurred during overtime for day-shift work. As counter measures: 1) adherence to 1 patient, 1 tray, and signing when matching; 2) as a counter-measure against mistaking specimens for blood gas hemolysis, confirmation as other specimens, separating approximately 3 drops of blood that cannot be used for sampling, confirming hemolysis, and preventing misidentification.

The design of high performance, low power triple-track magnetic sensor chip

This paper presents a design of a high performance and low power consumption triple-track magnetic sensor chip which was fabricated in TSMC 0.35 μm CMOS process. This chip is able to simultaneously sense, decode and read out the information stored in triple-track magnetic cards. A reference voltage generating circuit, a low-cost filter circuit, a power-on reset circuit, an RC oscillator, and a pre-decoding circuit are utilized as the basic modules. The triple-track magnetic sensor chip has four states, i.e., reset, sleep, swiping card and data read-out. In sleep state, the internal RC oscillator is closed, which means that the digital part does not operate to optimize energy consumption. In order to improve decoding accuracy and expand the sensing range of the signal, two kinds of circuit are put forward, naming offset correction circuit, and tracking circuit. With these two circuits, the sensing function of this chip can be more efficiently and accurately. We simulated these circuit modules with TSMC technology library. The results showed that these modules worked well within wide range input signal. Based on these results, the layout and tape-out were carried out. The measurement results showed that the chip do function well within a wide swipe speed range, which achieved the design target.

Vital signs monitors

The VSi, VS2+, and VS4 vital signs monitors are the newest members of the Philips SureSigns family. Our testing shows that they have a number of advantages. A major concern, however, is that vitals data could be associated with the wrong patient I.D. if the user deviates from the recommended workflow. Read our complete findings and judgments.

Infusion pump integration

A very small but growing number of hospitals have begun integrating their infusion pumps with their information systems and patient records. integrating your pumps can dramatically reduce infusion-related medication errors. But there are a number of significant barriers. Find out how the three main approaches to integration work, and learn some best practices for tackling the challenges.

Allergic reaction to a red plastic allergy alert patient identification bracelet: implications for surgical patient safety

We present a case of allergy to a hospital thermally-printed red plastic allergy alert bracelet in a 48 year old lady admitted to the day surgery unit. Two hours postoperatively, an intensely itchy area of erythema and oedema was seen extending from her left wrist distally to the fingers. The bracelet was removed and the rash resolved overnight without further complication. A diagnosis of contact dermatitis was made, secondary to exposure to an agent within the bracelet. We discuss the safety implications for surgical patients unable to wear an identification bracelet and the steps that may be taken to minimise the risk of harm from misidentification. We believe this to be the first documented case of an allergy to a patient identification bracelet in the medical literature.

Safe home program: a suite of technologies to support extended home care of persons with dementia

OBJECTIVE

To report the implementation/adoption of the Safe Home Program to support caregivers of persons with dementia in (1) ongoing surveillance, (2) provision of care, (3) prevention of injuries, and (4) improving home safety.

METHODS

For this demonstration project 4 assessment questionnaires (Safety Assessment Scale, Vigilance Scale, Peace of Mind Scale, and Sleep Disorders Inventory) were administered to each dyad to understand their technological needs. After identification and installation of appropriate technologies and education of the caregiver, a final visit (at 3 months) determined whether technologies were useful and being used.

RESULTS

The majority of caregivers utilized technologies for ongoing surveillance; other technologies included an identification program and medication organizer.

CONCLUSION

Technologies focused on ongoing surveillance for persons with dementia at the home are needed. These technologies could be quickly adopted by caregivers to ameliorate some of the stress and burden associated with providing care for persons with dementia.

Using computerised patient-alert system

SThe information technology systems used in most modern emergency departments alert staff to patients who require special management, including those with infections or histories of violence, or children on the child protection register. These systems can improve care for patients, protect staff and prevent infection, although their benefits must be weighed against the risks involved in storing sensitive data on computers. It is essential, therefore, that such systems are professionally maintained and updated. This article reports how one UK emergency department uses a computerised alert system to improve patient care.

Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors

OBJECTIVE

To determine whether the use of a computerized bar code-based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes.

PATIENTS AND METHODS

Our institution instituted a computerized bar code-based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010.

RESULTS

A total of 388,837 U were transfused during the 2002-2005 period. There were 6 misidentification episodes of a blood product being transfused to the wrong patient during that period (incidence of 1 in 64,806 U or 1.5 per 100,000 transfusions; 95% CI, 0.6-3.3 per 100,000 transfusions). There was 1 reported near-miss transfusion episode (incidence of 0.3 per 100,000 transfusions; 95% CI, <0.1-1.4 per 100,000 transfusions). A total of 304,136 U were transfused during the 2007-2010 period. There was 1 misidentification episode of a blood product transfused to the wrong patient during that period when the blood bag and patient's armband were scanned after starting to transfuse the unit (incidence of 1 in 304,136 U or 0.3 per 100,000 transfusions; 95% CI, <0.1-1.8 per 100,000 transfusions; P=.14). There were 34 reported near-miss transfusion errors (incidence of 11.2 per 100,000 transfusions; 95% CI, 7.7-15.6 per 100,000 transfusions; P<.001).

CONCLUSION

Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events.

Tackling incidents of violence, aggression and antisocial behaviour

Salford Royal NHS Foundation Trust has developed Sand implemented a strategy to reduce the number of incidents of violence, aggression and antisocial behaviour in its emergency department. The strategy, which includes the introduction of a nurse co-ordinator role and withdrawal of treatment from persistent offenders, has ensured the care environment is safer and calmer for patients and staff. This article discusses different aspects of the strategy and the ethics of withdrawing care from patients.

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial

OBJECTIVE

To evaluate systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study.

MATERIALS AND METHODS

In phase 1, from May to August 2010, the effectiveness of a 'retract-and-reorder' measurement tool was assessed that identified orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient as a marker for wrong-patient electronic orders. This tool was then used to estimate the frequency of wrong-patient electronic orders in four hospitals in 2009. In phase 2, from December 2010 to June 2011, a three-armed randomized controlled trial was conducted to evaluate the efficacy of two distinct interventions aimed at preventing these errors by reverifying patient identification: an 'ID-verify alert', and an 'ID-reentry function'.

RESULTS

The retract-and-reorder measurement tool effectively identified 170 of 223 events as wrong-patient electronic orders, resulting in a positive predictive value of 76.2% (95% CI 70.6% to 81.9%). Using this tool it was estimated that 5246 electronic orders were placed on wrong patients in 2009. In phase 2, 901 776 ordering sessions among 4028 providers were examined. Compared with control, the ID-verify alert reduced the odds of a retract-and-reorder event (OR 0.84, 95% CI 0.72 to 0.98), but the ID-reentry function reduced the odds by a larger magnitude (OR 0.60, 95% CI 0.50 to 0.71).

DISCUSSION AND CONCLUSION

Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.

Bagging, bumping, multiview, and active learning for record linkage with empirical results on patient identity data

Record linkage or deduplication deals with the detection and deletion of duplicates in and across files. For this task, this paper introduces and evaluates two new machine-learning methods (bumping and multiview) together with bagging, a tree-based ensemble-approach. Whereas bumping represents a tree-based approach as well, multiview is based on the combination of different methods and the semi-supervised learning principle. After providing a theoretical background of the methods, initial empirical results on patient identity data are given. In the empirical evaluation, we calibrate the methods on three different kinds of training data. The results show that the smallest training data set, which is obtained by a simple active learning strategy, leads to the best results. Multiview can outperform the other methods only when all are calibrated on a randomly sampled training set; in all other cases, it performs worse. The results of bumping do not differ significantly from the overall best performing method bagging. We cautiously conclude that tree-based record linkage methods are likely to produce similar results because of the low-dimensionality (p≪n) and straightforwardness of the underlying problem. Multiview is possibly rather suitable for problems that are more sophisticated.

"I meant that med for Baylee not Bailey!": a mixed method study to identify incidence and risk factors for CPOE patient misidentification

Computerized physician order entry (CPOE) systems can create unintended consequences. These include medication errors and adverse drug events. We look at a less understood error; patient misidentification. First, two email surveys were used to establish potential risk factors for this error. Next, an automated detection trigger was designed and validated with inpatient medication orders at a large pediatric hospital. The incidence was 0.064% per medication ordered. Finally, a case-control study identified the following as significant risk factors on multivariate analysis: patient age, last name spelling, bed proximity, medical service, time/date of order, and ordering intensity. These results can be used to improve patient safety by increasing awareness of high risk situations and guiding future research.

Indianapolis emergency medical service and the Indiana Network for Patient Care: evaluating the patient match algorithm

In 2009, Indianapolis launched an electronic medical record system within their ambulances1 and started to exchange patient data with the Indiana Network for Patient Care (INPC) This unique system allows EMS personnel to get important information prior to the patient's arrival to the hospital. In this descriptive study, we found EMS personnel requested patient data on 14% of all transports, with a "success" match rate of 46%, and a match "failure" rate of 17%. The three major factors for causing match "failure" were ZIP code 55%, Patient Name 22%, and Birth date 12%. We conclude that the ZIP code matching process needs to be improved by applying a limitation of 5 digits in ZIP code instead of using ZIP+4 code. Non-ZIP code identifiers may be a better choice due to inaccuracies and changes of the ZIP code in a patient's record.

Implementation of a card with instructions for patients treated for thyroid carcinoma with 131I

Patients discharged after their treatment with (131)I can become invisible sources of radiation for some members of the public. Even people who know that those patients have been treated with (131)I can easily forget the radiological risks that they represent. For this reason, it is essential to ensure that patients follow some instructions for a number of days until their remaining activity is low enough to irradiate members of the public under the recommended effective dose limits. Results in this study show that the number of days on which patients have to follow the mentioned instructions shows certain heterogeneity. Therefore, an individualised card with instructions given to patients after being discharged will tell them when they can restart their normal life, guaranteeing that members of the public do not receive an effective dose over the recommended limits.

An event driven hybrid identity management approach to privacy enhanced e-health

Credential-based authorization offers interesting advantages for ubiquitous scenarios involving limited devices such as sensors and personal mobile equipment: the verification can be done locally; it offers a more reduced computational cost than its competitors for issuing, storing, and verification; and it naturally supports rights delegation. The main drawback is the revocation of rights. Revocation requires handling potentially large revocation lists, or using protocols to check the revocation status, bringing extra communication costs not acceptable for sensors and other limited devices. Moreover, the effective revocation consent—considered as a privacy rule in sensitive scenarios—has not been fully addressed. This paper proposes an event-based mechanism empowering a new concept, the sleepyhead credentials, which allows to substitute time constraints and explicit revocation by activating and deactivating authorization rights according to events. Our approach is to integrate this concept in IdM systems in a hybrid model supporting delegation, which can be an interesting alternative for scenarios where revocation of consent and user privacy are critical. The delegation includes a SAML compliant protocol, which we have validated through a proof-of-concept implementation. This article also explains the mathematical model describing the event-based model and offers estimations of the overhead introduced by the system. The paper focus on health care scenarios, where we show the flexibility of the proposed event-based user consent revocation mechanism.