In 1998, when I started to work in my current position, the laboratory medical technologists said that one of the biggest problems they were having was that the patient wristbands were either missing or unreadable and asked me to help them with this. As a laboratorian, I was trained to get the right results, on the right patient, in the right amount of time, to right the physician. This concept seems simple enough, but it is not so easy when you deal with the myriad of challenges that a busy hospital deals with each day.
My first step was to benchmark our problem, and luckily the College of American Pathologists offered a Q-Track(TM) (http://www.cap.org/apps/docs/q_probes/past_studies/1993/wristband_identification_error_reporting.pdf) quality measurement tool in 1999 on exactly this problem. Six times a month, our phlebotomists gathered data on all the inpatients that they drew blood from, on whether they had a wristband on, and if it was readable and accurate. Each quarter we sent in our data to benchmark against the other hospitals that were participating in the study. Our results for that first measured quarter showed that we had a 12.9% wristband error rate. This confirmed what the technologists had believed to be true. We did have a problem.
I took the data to our CEO and discussed it with him and he asked me to share it with our Director of Nursing. When I spoke with her, her response was, “Well, every hospital has a problem with this, and we are no different.” Then I showed her the benchmark data on how we compared to other hospitals nationally. It was indisputable. We did have a problem. She asked me to begin an interdepartmental process improvement (PI) team to tackle the problem.
If I had not had the benchmark data, I would have never been able to get this PI project off the ground. It was a great communication tool and made it much easier to get full administrative support to tackle the problem.
Ten years later, we still measure the wristband error rate using the same Q-Track(TM) program. We still gather data six times a month to benchmark against the hospitals that continue to participate in the study. We now have a wristband error rate of less than 1%.
I believe that this is one parameter that we can never stop measuring. We need to measure what matters and patient safety is at the top of the list.
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