The number one patient safety goal in the country is proper identification of patients. There have been many unnecessary procedures and/or surgeries performed on patients over the years that should have been prevented because one or more members of the health care team either neglected to, or were afraid to check the patient’s ID.
About 8 years ago, I performed an x-ray series on the wrong patient, and I will never do it again. I was at an outpatient imaging center (where no wrist bands were worn). I called the patient’s name, and an elderly woman stood up and followed me toward the x-ray room. We were busy, so I didn’t bother asking for a date of birth because my paperwork said 80 years old, and she looked “about” that age. BIG MISTAKE!!! About one hour later, a patient with the same name inquired how long it would be from the front desk receptionist. You can imagine the confusion that followed when I informed the receptionist that I already performed the x-rays on that patient. After a considerable amount of time was spent sorting it out, I felt horrible because no one could identify the patient who I actually x-rayed (and who left an hour ago). Being busy is no excuse! Please learn from my mistake and verify name and date of birth in an outpatient setting with no wrist-bands.
I have heard exponentially worse stories of surgical teams who suspected that they were operating on the wrong patient, but were afraid to say anything because of a Physician’s demeanor. Remember, you are the patient advocate just like everyone else on the health care team. You can still check a wrist-band without making a big production, and you MUST inform the Physician if there is a discrepancy. It’s not only the Physician that is liable, but every member of the health care team who came in contact with the patient, and should have confirmed ID.
You should always check the patient wrist-band in a hospital setting. Two identifiers are required, but I suggest that three should be verified by all Technologists: Patient name, date of birth, and medical record number. If it is an outpatient, simply look at their wrist band while in the waiting room, and wait until you are behind closed doors to verbally verify ID. Inpatients can be visibly checked in the hallway while waiting for an x-ray room to become available, but should also be verbally verified once in the exam room. Please remember to protect their privacy.
It’s hard to admit that you have done something wrong, and sometimes it can be very painful, but no one will benefit from a mistake unless the error can be identified and steps are made to further prevent the same error in the future.
I've worked in various hospitals for more than a decade and can report that most Techs are unaware of the Universal Protocol. Moreover, I've known several Techs perform exams on wrong patients and subsequently when informed of their mistakes, deflected the blame on the nurses or ward clerks who generated the requisitions for those exams.
ReplyDeleteWhile I was attending college to attain an AAS in Radiology, all of my professors inculcated, almost on a daily basis, in their students the importance of requiring two forms of identification prior to performing any exam,along with asking the patients about their chief complaints.
I've worked in various hospitals for more than a decade and can report that most Techs are unaware of the Universal Protocol. Moreover, I've known several Techs perform exams on wrong patients and subsequently when informed of their mistakes, deflected the blame on the nurses or ward clerks who generated the requisitions for those exams.
ReplyDeleteWhile I was attending college to attain an AAS in Radiology, all of my professors inculcated, almost on a daily basis, in their students the importance of requiring two forms of identification prior to performing any exam,along with asking the patients about their chief complaints.
I'm working as a Lead tech now, and probably change orders for incorrect exams or patients at least 2-3 times per day. Our hospital system takes this very seriously... you will at least be suspended, if not terminated, for performing exams on the wrong patient. If suspended, you WILL be terminated the second time you do it, no questions asked.
ReplyDeleteJeremy, I'm glad to hear your facility has standards and enforces them. Unfortunately, I work at hospital that's totally unfamiliar with work ethics. Most of the staff have the mentality that what the patient doesn't know won't hurt him. I took the position at this hospital due to shift position and pay increase, and I've been regretting my decision since day one.
ReplyDeleteLastly, I've worked with numerous healthcare providers throughout my career, including RTs, that could care less about the ARRT's Code of Ethics unless there has been legal action initiated against the hospital and/or staff members. Then, it becomes a convenient tool to scapegoat (i.e., dismiss) a RT displaying for management that the situation has been rectified.
Jeremy, I'm glad to hear your facility has standards and enforces them. Unfortunately, I work at hospital that's totally unfamiliar with work ethics. Most of the staff have the mentality that what the patient doesn't know won't hurt him. I took the position at this hospital due to shift position and pay increase, and I've been regretting my decision since day one.
ReplyDeleteLastly, I've worked with numerous healthcare providers throughout my career, including RTs, that could care less about the ARRT's Code of Ethics unless there has been legal action initiated against the hospital and/or staff members. Then, it becomes a convenient tool to scapegoat (i.e., dismiss) a RT displaying for management that the situation has been rectified.
I think that facilities will spend less time (and indirectly, $$$) on upholding these standards. The fact is, we are liable for performing these ID verification steps regardless of whether or not your employer makes a conscious effort to promote them. Hopefully, we can remember what we were taught in school while realizing that we each have the capability and responsibility to maintain our integrity in upholding the Code of Ethics that we once recited.
ReplyDeleteMy concern about the punishment of misidentification of imaging patients is that, because of the fear of losing one's job, professionals who know they ethically should do everything to correct the error, may not.
ReplyDeleteWe should always be much more concerned about fixing the problem than punishing individuals.
Repeated offenses, yes, should result in termination. Isolated incidents should be taken on a case-by-case basis and the resulting outcome of the situation should absolutely always be taken into consideration (effect on patient).
My concern about the punishment of misidentification of imaging patients is that, because of the fear of losing one's job, professionals who know they ethically should do everything to correct the error, may not.
ReplyDeleteWe should always be much more concerned about fixing the problem than punishing individuals.
Repeated offenses, yes, should result in termination. Isolated incidents should be taken on a case-by-case basis and the resulting outcome of the situation should absolutely always be taken into consideration (effect on patient).