Archive for November, 2009|Monthly archive page

Safety Precautions for Patient ID checks during Critical Procedures

In Hospital Management, New/Converging Technologies on November 3, 2009 at 03:23
On October 22nd, an Antwerp Hospital mistakenly switched 2 male patients in the Operation Room. One seems to have had the others prostatectomy, the other got examined under anesthesia. The latter got his prostatectomy later, after it came to attention he still needed one.
One of  them had his name bracelet taken off  for an I.V. cannula placement. The nurse, so they now say, may have forgotten to put it back on.
This is something that cries for novel technology solutions.
It is painstakingly true, that almost no hospital in Western Countries of Europe can boast a system that can identify a patient with a system that makes the necessity for a cognitive interaction, during the process that is considered critical, obsolete or simply unnecessary.
There where people usually attribute a higher level of certainty  to the implication of human judgment in a safety procedure, it may well be that this human appreciation should be made before the start of any Highly Safety Dependent Procedure. The sheer knowledge of the existence of the possibility that several intricate processes may go wrong is sometimes enough to create a base line of stress, which in turn may ignite cognitive mistakes.
If a patient’s identity is crucial to the safety and further development of care processes, which it undeniably always is in a hospital, a separate identity verification should be considered as a necessary SEPARATE logged and verifiable procedure before the critical process begins.
During the different stages of the critical procedure (like an operation, an invasive test, or a examination under anesthesia) a verified identity is remaining attached in a procedurally indelible way to the patient. In our view, this may well be a specially designed sophisticated electronic identification, unique to the patient, and not removable.
This way, during the critical process itself, only positive appreciations or checks of a technological and preferably not (inter)changeable parameter can establish the identity of the patient.
It goes without saying that the checks should not be dependent on the reach of the attention span of one, let alone several singular persons, to allow  for mistakes to happen.
On the contrary, the technology should be automated, and  a report of the several automated checks, along with a report of the initial and original verifiable identity procedure carried out separately BEFORE THE START of the critical procedure should be reviewed and “signed” by the surgeon about to operate on the patient.
At this point in time, this methodology has been clearly defined and used in environments very different from hospitals. In factory production environments, logistic relay stations, railway solutions, airplane logistics, and in many other circumstances less strange to you than you may well think, this kind of adaptation is considered a normal part of the process.
Maybe we can learn from from our fellow humans in the field?
I sure know I would like to keep my private parts!