Wristband risk to patient safety highlighted

Tags: A Audit Dispensing England iS NPSA Patient safety Quality RFID Safety Surgery Wales Wristbands

24 Nov 2005

A drive to raise awareness of the importance of patients wearing hospital wristbands should make barcode and RFID technology more effective and help prevent errors.

The initiative launched this week by the National Patient Safety Agency (NPSA) was discussed at a healthcare group meeting of Intellect, the trade association for the UK's high tech industries.

Chris Ranger, NPSA head of safer practice, underlined the importance of technology in preventing some of the errors that cause 572,000 ‘patient safety incidents’ a year in England and Wales and result in an estimated 840 deaths.

In addition to the human cost, she added: “£2bn is spent on extra days in hospital in England [per year] because of adverse events. There’s a business case here.”

The problems with wristbands have been sufficiently common to prompt the NPSA to issue guidance in the form of a safer practice notice. The agency says that between November 2003 and July 2005, it received 236 reports of patient safety incidents and near misses relating to missing wristbands or wristbands with incorrect information.

“Mismatching patients and their care can result in serious, lasting harm such as chronic pain, undiagnosed cancers, blindness and even death,” the agency says.

The safer practice notice follows the publication in December 2004 of the NPSA’s report 'Right patient – right care' which identified areas where manual checking can be improved and technological advances can be used to ensure that patients are correctly identified and receive the right medication and care.

Ranger outlined the commonest types of errors at the meeting and concluded: “No single technology meets all the requirements. Barcoding is the current and best technology for avoiding mismatching, but RFID is potentially a more powerful tool.”

She emphasised that technology had to be useable, efficient and hard to overwrite.

In addition to the wristband awareness campaign, Ranger said the NPSA would be looking at ways to standardise initial patient identification and to make laboratory investigations safer.

“Most mistakes happen before specimens reach the lab and when results are returned. We’re looking for ideas,” she said.

In a meeting themed on patient safety, other speakers looked at international comparisons and some practical examples of how the NHS is using technology to address safety.

Mats Larson of Oracle, who is also president of the European Health Telematics Association, looked at developments around Europe and emphasised the need for co-operation across national boundaries to support the increased mobility of patients and professionals.

Alison Terry, audit manager of the National Audit Office’s health value-for-money studies, looked at NHS initiatives which have used technology to improve patient safety. These included investment in document scanning to improve the quality of hospital case notes; the use of RFID to reduce the risk of wrong site/wrong site surgery and the introduction of robots to support automatic dispensing and cut drug errors.

Readers Comments

not all plain sailing

28 Nov 05 16:01

Whilst I support the rollout of machine readable bands to promote safer working practices in drugs admin/procedure process. I should pass on a comment from a former coleague who visited a USA site using bar coded meds admin. There a night nurse had a copy of all her patients wrist bands attached to her belt. She commented, sometimes the patients are asleep, this way I can wand the bar code I have and avoid rolling them over and waking them up.......

Right patient, right care

colin@kineticconsulting.co.uk

02 Dec 05 08:52

Amusing though the "not plain sailing" anecdote is, one of the advantages of using RFID wristbands in that the night nurse would not need to wake patients.

HF RFID tags can be read through clothing and at almost any orientation.

The NPSA is on the right track. I think AutoID technologies like RFID will transform healthcare in many ways, so let's try to be more positive about developments like this.

Is it not tragic after 50 years in business that about 10 percent of NHS inpatients receive inappropriate treatment?

London Underground carries about 1bn passengers a year. Imagine ten percent of travellers to Heathrow getting on the west-bound Piccadilly line and being dumped at West Ruislip.