Abstract
Patients, consumer advocacy groups, and regulatory and accrediting bodies have spoken out about the importance of patient safety in the health care environment. Understandably, patient safety is a leading concern for both consumers and health care providers. These efforts have encouraged health care organizations and providers to review and revise, as necessary, routine practices that contribute to a culture of patient safety and avoid medical errors. This article outlines the process and outcome of a performance improvement initiative to develop a standard patient identification policy.
There has been increasing media attention to issues of patient safety in health care. A consistent flow of news reports regarding breaches of patient safety are detailed by examples of "medical errors" such as incorrect procedures or treatments being performed on the wrong patient. In addition, patients, consumer advocacy groups, and regulatory and accrediting bodies have spoken out about the importance of patient safety in the health care environment. Understandably, patient safety is a leading concern for both consumers and health care providers. These efforts have encouraged health care organizations and providers to review and revise, as necessary, routine practices that contribute to a culture of patient safety and avoid medical errors.
In July 2001, the Joint Commission on Healthcare Organizations (Joint Commission) introduced revisions to its standards manual1 emphasizing patient safety. Standards were either revised, enhanced, or added under the following chapters: "Leadership," "Performance Improvement," "Management of Information," "Patient Rights and Organization Ethics," "Education," "Continuum of Care," and "Management of Human Resources." To strengthen the safety standards, the Joint Commission released the following in its August 2002 Internet news brief:
The Joint Commission's Board of Commissioners has approved for implementation effective January 1, 2003 a set of six National Patient Safety Goals representing 11 recommendations for improving the safety of patient care in health care organizations.
The Joint Commission 2003 National Patient Safety Goals and associated recommendations are:
1. Improve the accuracy of patient identification.
a. Use at least two patient identifiers (neither to be the patient's room number) whenever taking blood samples or administering medications or blood products. [horizontal ellipsis]2
Consumer advocacy groups and professional organizations such as the Agency for Healthcare Research and Quality, Institute for Healthcare Improvement, and Institute for Safe Medication Practices are continuously publishing or posting to their Web sites information regarding medical errors and patients.
At Memorial Sloan-Kettering Cancer Center, the importance of clarifying defined standards for patient identification was recognized as an essential initiative to enhance the existing culture and environment of safe patient care. Correct patient identification is essential prior to delivering care, treatment, or service. This becomes increasingly important in an environment where high-volume and/or high-risk procedures and treatments are delivered.
Clarifying, defining, or establishing processes or developing a standard of care in large complex organizations is always a challenge. An initial review and analysis of the identified process often indicates variation in its application across the organization-typically the impetus for the change. This makes it imperative that all identified stakeholders participate in the performance improvement process and that a team reflective of the stakeholders be established. To ensure the team's success, all attempts at seeking appropriate representatives must be explored. This does not always lend itself to the small team of 8 to 12 members recommended in the performance improvement literature.3 However, with appropriate planning and facilitation, a larger team is manageable.