Pilot Results:

• Number of patients in pilot: 77
• Average length of stay in the unit: 6.2 days
• Number of wristbands used: 77 (for the 77 patients)
• Wristbands worn for an average of 6.4 days
• Scanability: 98.7 percent (76/77)
• Durability: 100 percent
• Pilot glucometry results:
  • 158 glucometry results
  • 35 patients
  • Errors: 0/158 (0 percent)
  • Recording patient ID: Manual data entry compared to bar code scanning
    • Before pilot: 2/170 (1.2 percent)
    • During pilot: 0/158 (0 percent)
    • After pilot (reverting to prior, non-bar coded wristbands): 2/134 (1.5 percent)
    • Statistically significant (by chi-squared analysis, p <0.005)

Nursing Survey Results:

• Found the technology to be easy to use and efficient

• Change in the display format of the patient demographics on the wristband
  • Change in font
  • Change in content
• Change in the designation of patients with allergies:
  • Single colored wristband: white
  • No color coded wristbands for patients with allergies
• Change from a barcoded label approach to a direct thermal wristband approach

• We piloted and implemented 1 and 2D bar coded patient wristbands at our institution in an effort to reduce patient misidentification. 
• We are currently involved in institution-wide efforts to standardize the structure of the information on the 2D wristband bar code so that essential data elements can be recognized and shared by numerous applications (electronic medication administration, smart IV pumps, EKG machines, radiology applications). 
• We envision the wristband bar code being the link to critical medical information stored in the medical record but the wristband itself would not contain this data since the data is subject to change.
• A key aspect of our strategy was to create a sense of urgency within the institution regarding the need for improved patient identification. 
• We overcame the issues of “ownership” and resource allocation for the project by obtaining acknowledgment from senior management that bar coded wristbands are an essential piece of infrastructure for enabling numerous initiatives.
• The institution has made a decision to excel and become a high reliability organization by adhering to principles of high reliability organizations: Prevent, Identify and Mitigate. 
  • The current process is designed to prevent failure resulting from misidentification of patients. 
  • A periodic monitoring system will identify issues when they arise. 
  • Procedures for mitigating the harm caused by failures include limiting the inclusion of medical information on the patient wristband to prevent “stale” data from causing medical error.

Arjun C. Rao, MBBS, MBA, Senior Project Specialist
Massachusetts General Hospital
arao1@partners.org

[Storyboard presentation at IHI's National Forum, December 2005]