Becker's Clinical Quality & Infection Control

26 INFECTION CONTROL & PATIENT SAFETY Study: Risk of Patient Identification Errors 'Ever-Present' By Kelly Gooch F ailing to associate the right patient with the appropriate action, referred to as wrong-patient errors, is a prevalent occurrence with potentially fatal conse- quences, according to a report from the ECRI Institute, a nonprofit research group that studies patient safety. e ECRI report examined 7,613 wrong-pa- tient events occurring from January 2013 to July 2015 that were submitted by 181 health- care organizations. e events were voluntarily submitted and may represent only a small portion of all wrong-patient events occurring at the organizations, ECRI officials said. Of the 7,613 wrong-patient events studied, about 9 percent led to temporary or perma- nent harm or even death. "Although many healthcare workers doubt they will actually make a mistake in identifying their patients, ECRI Institute PSO [Patient Safety Organization] and our partner PSOs have collected thousands of reports that show this isn't the case," Wil- liam M. Marella, ECRI Institute executive director of PSO operations and analytics, said in a statement. "We've seen that anyone on the patient's healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists and transporters." e report found that the majority of wrong-patient events (72.3 percent) took place during patient encounters, while another 12.6 percent occurred during the intake process. Also, researchers said, more than half of wrong-patient events involved either diag- nostic procedures (2,824 or 36.5 percent) or treatment (1,710 or 22.1 percent). Diagnostic procedures cover laboratory medicine, pathol- ogy and diagnostic imaging. Treatment covers medications, procedures and transfusions. Additionally, the report found the majority of the events for which a harm score was provided, using National Coordinating Council for Medication Error Reporting and Prevention, were caught before they caused any harm (1,601 of 1,752 events, or 91.4 percent). And the two wrong-patient events associat- ed with patient deaths involved documenta- tion failures; in one event, the wrong patient record was accessed, and in the other event, the wrong patient's documentation was used to give another patient clearance for surgery, researchers said. "ECRI Institute PSO's Deep Dive analysis of wrong-patient events shows that the risk of errors is ever-present for the multitude of pa- tient encounters occurring daily in healthcare settings," they concluded. "ese events occur during multiple procedures and processes and can involve nearly anyone on the patient's healthcare team. As a result, no single strategy can prevent these events; instead, organiza- tions must adopt a multipronged approach to prevent wrong-patient mistakes." e researchers recommended leaders of healthcare organizations communicate to staff the expectation that patient identifica- tion is essential for safe care and is an orga- nizational priority; ask questions about the organization's patient identification practic- es and experiences to identify strengths and opportunities for improvement; and provide support for the organization's patient identi- fication improvement initiatives. n Audits and Feedback or Incentives: Which Will Boost Hand Hygiene Compliance More? By Heather Punke W hen it comes to boosting hand hygiene com- pliance rates, incentives are a quick fix, but auditing and providing feedback results in sustained high compliance levels, according to a study in the American Journal of Infection Control. As part of the study, nurses at a Lebanese hospital partic- ipated in a lecture about the World Health Organization's My 5 Moments for Hand Hygiene and then were divided into three groups: a control, an incentive-based group and an audit-feedback group. The incentive-driven group included 33 nurses who were evaluated by auditors. Then, a staff meeting was held ev- ery week in which the two winners — who had the second highest and highest hand hygiene score — were given money as prizes. The winner received the equivalent of one overtime shift payment, and the nurse in second received 75 percent of that amount. However, the nurses in this group received no detailed feedback. In the audit-feedback group, 29 nurses received feed- back on hand hygiene compliance as a group and also in- dividually during weekly meetings. The feedback includ- ed giving them their scores, their missed hand hygiene moments and a reminder about the importance of hand hygiene compliance. The audits took place over a 21-week period, but feed- back and incentives were only given through week 14. During the 14-week intervention period, hand hygiene compliance improved in both groups — from 21 percent to 77 percent for the incentive group, and from 23 per- cent to 51 percent in the audit-feedback group. However, after the interventions stopped, the incen- tive-based group's compliance rate dropped to 34 per- cent, while the audit-feedback group's compliance rate hovered around 48 percent. The study's authors concluded multifaceted interventions are the best way to achieve and sustain hand hygiene compliance. n

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