I’ve Been Thinking about Sarah Palin, Tina Fey, hospital admitting, and positive patient ID

I’ve been thinking about Sarah Palin, Tina Fey, hospital admitting, and positive patient ID.

It looks likes Tina Fey’s role as Sarah Palin has finally entered hiatus. However, don’t be surprised if Saturday Night Live flies Sarah from Anchorage to the Big Apple for an encore appearance as Tina.

Speaking of look- and sound-alikes, the U.S. Pharmacopeia tells us that over 1,400 drugs have been confused because their names look and sound alike. So much for drugs. What about patients? Do you remember Joe The Plumber? In addition to Joe Da Plumber, Joe Teh Plumber, and Joe T Plumber, Facebook lists over 400 Joe Plumbers. Whitepages.com lists 1,800! That’s nothing. The historian of the Jim Smith Society, Jim Smith, tells me over 80,000 Jim Smiths are scattered across America.

In the preface of the 2009 National Patient Safety Goals, The Joint Commission (TJC) warns of a clear and present danger: “Wrong-patient errors occur in virtually all aspects of diagnosis and treatment.”

For the seventh year in a row, TJC’s number-one goal is to “improve the accuracy of patient identification.” And, once again, this goal is followed by requirement 1A: “Use at least two patient identifiers when providing care, treatment or services.”

I would also like to point out that that this year, for the first time, TJC has openly blessed the use of “automated identification technology such as bar coding” as one of the means for improving patient identification. You can imagine how delighted I am that TJC has finally used the B word.

Prior to addressing the Swiss GS1 Bedside Barcoding Conference last September, meeting planners requested my picture for their promotional materials. I was needlessly flattered as it turned out that they merely wanted the second identifier so prospective attendees would not mistake me for Mark Neuschwander, VP board of directors, Bayer Switzerland.

Pictures would be helpful for differentiating Tina Fey from Tammy Faye but not so useful for telling Tina Fey from Sarah Palin. By the way, I am guessing that you did not notice that Bayer’s Neuschwander is two letters shorter than my Neuenschwander.

Patient mix-ups don’t require similar names. A young woman told me that she ended up in a hospital with severe pain, in deep depression, and completely exhausted. When her boyfriend joined her in the ER, he noticed (after medications had been administered) that her wristband bore another patient’s name—a name that was nowhere near hers. While she had some unpleasant complications, fortunately she had no serious injuries.

Often I have said that the efficacy of bedside scanning depends on the accuracy of bar-code labeling on drug packaging. Likewise, the efficacy of bedside scanning depends on the accuracy of bar-code labeling on patients’ wristbands.

The young woman I talked to did not remember if her wristband had a barcode. If it did, I’d bet you all the elk in Alaska that it also mapped to some other patient. Hospitals that have poor processes for producing and applying wristbands before implementing BPOC will probably have poor processes afterward. Technology doesn’t heal poor process.

For BPOC to work properly, it is important that all products be scanned as they arrive in pharmacies to verify that they accurately map to the hospital’s drug databases. Obviously, patients do not arrive at hospitals bearing bar codes. This calls for “designing rigorous procedures to error-proof the process of patient wristband application.”1

When admitting clerks verify names and dates of birth and printers issue bar-coded wristbands, it should not be assumed that these barcodes are correct. Clerks should scan each new patient’s wristband to verify that the record it retrieves belongs to the person they are getting ready to send off to treatment. And when wristbands have to be replaced, the same verifying process should be required.

I was blessed with good health while traveling in Switzerland. But it did occur to me that were I to have landed in a hospital, I would not have wanted to be tagged with a barcode that mapped to the other Mark Neuschwander.

In summary, bar-code scanning does not negate TJC’s requirement for that second identifier. Scan me and ask me. April 14, 1948. Thank you very much.

What do you think?

Mark Neuenschwander
mark@hospitalrx.com

1. Barcoded Medication Administration: A Last Line of Defense, Cescon and Etchells, JAMA. 2008;299(18):2200-2202 (doi:10.1001/jama.299.18.2200)