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Right patient, right care: wristbands and patient safety

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The electronic identification of patients greatly reduces the risk of errors and ensures more reliable matching of patients with care intended for them

Chris Ranger
Partnership Development
Manager
NPSA

Identifying patients accurately and matching them with care intended for them, such as the right medication or the right blood, is fundamental for healthcare staff when delivering safer treatment every day.

Recognising this, the National Patient Safety Agency (NPSA) advises that all hospital inpatients must wear wristbands with correct patient identifiers and that wristbands should be able to incorporate barcodes and radio tags so as to enable electronic matching of patients with care, which will minimise the risk of any mix ups.

The Healthcare Select Committee’s latest report on patient safety (July 2009)[1] similarly recognises that automatic identification and data capture technology (AIDC) such as barcoding and radio tagging, has the potential to reduce patient safety errors significantly. Impressive pioneering advances, such as the administration of medication at the Charing Cross Hospital, are being made, but the Select Committee has serious concerns about the slow uptake of the use of technology across the NHS.

Background to the NPSA’s wristband recommendations
Safer Practice Notice of July 2007
To facilitate the electronic identification of patients and eliminate the risks associated with illegible handwritten wristbands, the NPSA issued a Safer Practice Notice (SPN)[2] in July 2007 that required all NHS organisations in England and Wales that use patient wristbands to generate and print these from the hospital demographic system (such as the Patient Administration System; PAS), and by the patient’s bedside wherever possible. This action should have been completed by 18 July 2009. One of the questions raised with the NPSA is whether this means that there should be a printer at every patient’s bedside, which it does not. What is intended is that each wristband should be printed next to the patient so that details can be checked with the patient. The wristbands must not be printed before the patient arrives as this will increase the risks of wristbands getting mixed up or wrongly allocated. The SPN also sought to standardise wristbands so that any member of staff working in the NHS would know what information to expect on a patient wristband and where to find it. The NPSA advised relevant NHS organisations to implement these recommendations by 18 July 2008. The core patient identifiers- that is, last name, first name, date of birth and NHS number- should all be included and any other identifiers deemed necessary should be risk assessed before their inclusion. The recommendation is backed
up with design requirements for wristbands.[3]

The SPN emphasises the need for clear and consistent processes for producing, applying and checking wristbands, and the colour of wristbands- they should be white with black text. Where a healthcare organisation feels they must use colour to identify a patient risk, the wristband should be red with black patient
identifiers.

Previous NPSA guidance on wristbands
The SPN is the latest output from the NPSA to promote safer patient identification. Prior to this, the agency published Right patient, right care (2004) which reported on the use of manual methods and technologies to identify patients and match them with care. This found that the lack of wristbands or those with missing or inaccurate details were both serious risks to patient safety. One snapshot study[4] at St Thomas’ hospital showed that on one day in 2003, 34 percent of inpatients were not wearing any wristband at all.

Subsequently, in November 2005 the NPSA issued its SPN[5] recommending that all NHS acute hospital inpatients should wear wristbands that accurately identify them and make effective arrangements for implementing and monitoring this action.

Compliance with the SPN recommendations
Compliance with all the recommendations of the July 2007 SPN in England is measured through the Department of Health’s Central Alerting System (CAS). This data is based on what trusts report themselves. A check of this data on 7 September 2009 showed:

  • 67% report that they need not take action or that they have completed their actions.
  • 27% report that they still have work ongoing.
  • 6% report that they have not started taking action.

The NPSA will evaluate compliance with its SPN across England and Wales towards the end of the year, in order to clarify the issues where NHS organisations have not fully completed the actions or have not even started them.

Some NHS organisations may have been unable to implement the recommendation which states that all patient wristbands should be generated and printed from the hospital demographic systems, within the two-year timeframe-that is, by 18th July 2009. Such healthcare organisations should have informed their Strategic Health Authority (SHA) or the Welsh Assembly Government (WAG) of the reasons why, and agreed a plan with their SHA/WAG that includes concrete and deliverable timescales.

Wristbands for neonates and children
The patient identifiers which go on a neonate’s wristband are different to those for other adult and child patients, as the neonate’s name may not be decided on and their unique NHS number can only be generated once their birth details have been entered on to the hospital’s computer system. The NPSA advises that in these cases, a wristband with a temporary number must be given until the NHS Number has been allocated- for the NPSA’s full advice see the leaflet on identification of neonates at http://www.npsa.nhs.uk/nrls/alerts-and-directives/notices/wristbands/. Once the NHS number is allocated, a second, printed wristband containing the identifiers specified in the NPSA’s advice (including their new NHS Number) must be given as a replacement.

The NHS Number Programme at NHS Connecting for Health, and the NPSA, are currently investigating longer term solutions to this issue as there may be problems ensuring safe patient identification if, for example, an emergency admission to neonatal intensive care is required before the neonate has an NHS Number- one proposal is to assess whether an NHS Number could be issued before birth. Although the design requirements for wristbands state that the identifiers should be in “a minimum font size of between 12 and 14 point (equivalent to a height of 2-2.3mm)” (paragraph 5.9) some organisations have experienced difficulties in achieving this with the smaller wristbands needed for neonates and younger children. The NPSA therefore advises that reducing the font size below 12 is acceptable in these cases, providing that the identifiers remain clear and are easily comprehensible.

Use of labels and wristbands
Queries have been raised with the NPSA about the use of pre-printed labels and the risks associated with these being used for the wrong patient’s wristband.
The NPSA recommends:

  • It is unsafe to print several labels with the patient’s details at one time, so that they can be used as required for their care.
  • Instead, labels should be printed as and when required for the patient’s care and, where electronic systems permit, by the bedside so that the risk of the label being used for another patient is minimised.

Information Standards Board standard
The NPSA and NHS Connecting for Health worked together on a standard format for printing patient identity bands/wristbands which was approved by the Information Standards Board for Health and Social Care (ISB) in March 2009. It is based on the NPSA’s standardising wristbands SPN and related design requirements. The ISB issued a Data Set Change Notice which requires IT Suppliers to conform by 31 December 2010. The standard will ensure that identifiers are printed consistently and clearly, hence supporting safe clinical practice. The standard means that those computer systems that do not yet print identity bands in the recommended format will need to be updated.

Conclusion
The electronic identification of patients greatly reduces the risk of errors and ensures more reliable matching of patients with care intended for them. Complying with the SPN recommendations discussed here, enables healthcare organisations to introduce electronic systems more easily.

Pioneering healthcare organisations are using electronic patient identification systems based on barcoding and RFID technologies in patient wristbands to facilitate safer care. As the Healthcare Select Committee stated in their latest report, this needs wider and faster adoption across the NHS.

References
1. House of Commons Health Committee: Patient Safety: Sixth Report of Session 2008-09, volume 1. July 2009.
2. National Patient Safety Agency. Safer Practice Notice: Wristbands for hospital inpatients improves patient safety. London, November 2005.
3. National Patient Safety Agency. Your guide to implementing standard wristbands; 2007 www.npsa.nhs.uk
4. Guthrie, D. Positive Patient Identification. Frontiers in Laboratory Medicine. The Royal College of Physicians: London, February 2003. National Patient Safety Agency. Safer Practice Notice: Wristbands for hospital inpatients improves safety. London, November 2005.
5. National Patient Safety Agency. Safer Practice Notice: Wristbands for hospital inpatients improves safety. London, November 2005.



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