April 21, 2006

NPSA Patient Wristband Specification

The National Patient Safety Agency (NPSA) is developing a standard specification for patient wristbands in the NHS in England and Wales. This second phase of work follows from earlier guidance issued in November 2005 and reported in this FHIT entry.

In Right Patient, Right Care the NPSA has already noted that mismatching patients and care is a serious and costly problem. It can be caused by patients not wearing a wristband, or by wearing one that provides unreliable identifiers. Between November 2003 and July 2005 the NPSA received 236 reports of patient safety incidents relating to missing or unreliable wristbands.

The NPSA's work is closely linked to other initiatives, such as:

  • Blood transfusion safety;

  • Medication safety;

  • Research into bedside checking of patients and care; and

  • Work with NHS CFH and Informing Healthcare.

You can read the full briefing sheet download file.

March 18, 2006

Right patient, Wrong Site—Right Technology?

rfid-healthcare-reader.jpgAnother tragic wrong site error in the UK remarkably similar to the Graham Reeves case referred to in this FHIT entry on patient safety.

That entry also notes that Radio Frequency Identification (RFID) may help to prevent this kind of right patient, wrong site error. The UK's Birmingham Heartlands Hospital is piloting RFID and W-Fi tagging and linking them to a picture of the patient on the EPR. I do not know the details of this pilot, but I would be surprised if it is a panacea, because the possibility of human error is not eliminated.

I listened to a talk the other day about the implementation of RFID in a hospital in the Netherlands. It confimed what I already knew: RFID application is still as much an art as a science. Even when readers are suitably located, tag and antenna alignment is still a problem. In addition, even if RFID could be used to trigger alerts, say in the operating theatre, they would have to compete with ambient stimulae and the noise of anaesthetic equipment, staff coming and going, respirators etc.

I am convinced that radio technologies are important in the evolution and integration of healthcare IT; I am still to be convinced that RFID will be any more than one of many of them.

January 30, 2006

Reposting for Eyeforhealthcare Delegates

This is a re-post of three entries about the increased mortality reported in “Pediatrics” after the implementation of a Computerised Physician Order Entry System (CPOE) for the convenience of delegates at the “Successful Implementation of NPfIT 2006” in London. These entries relate to discussions during the sessions I chaired on 30 January 2006.

First entry on the Pediatrics article.

Second entry on the article.

Third entry and link to post-publication peer review.

Links to other relevant blogs and websites are in the postings.

January 04, 2006

Health IT: making care better or worse? (cont)

The debate about the sharp increase in mortality reported in Pediatrics after the implementation of a computerised physician order entry system (CPOE) at the Children's Hospital in Pittsburgh. (See FHIT entry) rumbles on.

I spotted this reference to a post-publication peer review, which states:

“A more accurate summary of the findings is that there were significant problems with the implementation process for CPOE at this hospital and that the hospital simultaneously instituted other system changes that may have accounted for adverse effects.”

Compounding the criticism of the study by health IT experts and others, the hospital’s medical director and other hospital officials have also disagreed with the study's findings, according to the Wall Street Journal.

In the UK the original study was also picked up by the E-Health-Insider website. Please look at the comments after the article, which are instructive and tell us about the polarisation of opinions on healthcare IT in the UK.

Even after 15 years of implementing health care IT it never ceases to astonish me how quick people are to criticise it and how little healthcare has learned about its implementation.

Implementing information systems without first changing processes and medical practice to accommodate them and carefully monitoring the result is folly, not to say negligence. This applies doubly to processes that may already be poor.

How long will it take us to learn these lessons?

More on the on the eHealth Blog.

December 06, 2005

Patient safety: safer on a plane than in hospital

Liam Donaldson, Britain's Chief Medical Officer, says that we may be safer on a plane than in hospital. It seems the risk of being killed by a medical error in a developed country is about 1 in 300; the risk of dying in an air accident is 1 in 10 million.

Actually, it depends whose figures you take. The NAO recently said (PDF) that more than 2000 people a year die as a result of medical errors. The most common causes of error are: patient injury (due to falls), followed by medication errors, equipment related incidents, record documentation error and communication failure.

The NAO admits that the actual number of deaths by medical accidents is unknown, and there may be significant under reporting. Estimates range from 840 to 34,000 a year.

Based on Liam Donaldson's ratio and using an estimate of about 8m admissions to the NHS annually based on the NPSA report "Right Patient, RIght Care" (PDF), this would put the number of deaths caused by medical errors at about 26,000 a year.

December 04, 2005

Patient safety and wristbands

I went to a meeting organised by "Intellect" (the UK's trade association for the IT industry) recently. The National Patient Safety Agency (NPSA) launched an intitiative to increase awareness of the importance of patient wristbands in patient safety. Incorrect patient ID is thought to be one of the main causes of "patient safety incidents".

Chris Ranger, the NPSA's head of safer practice, used the case of Graham Reeves, who had his remaining healthy kidney removed by mistake, to illustrate the potentially tragic consequences of human error in healthcare.

Even those NHS trusts that use patient wristbands do so inconsistently: some blue for men and red for women and some the opposite, for example!

Barcodes have been used for some time in healthcare and are still a reliable stalwart for wristbands, but please see this amusing anecdote posted on the E-Health Insider website (look at the first comment at the end of the article)about how clinical staff can "innovate" with them.

Both Chris Ranger and Alison Terry of the National Audit Office mentioned RFID as a technology with the potential to improve patient safety, either by allowing more confident patient-ID or by helping to prevent wrong patient, wrong site errors.

The NPSA has launched a briefing paper (PDF) on the use of patient wristbands.

The NPSA says, however, that wristbands do not remove clinicians’ responsibility for checking patients’ identity. They are an important way of validating identification particularly when a patient is unable to provide their own details.

Like all aids to identification, barcodes and RFID carry the risk that we "believe" them; cross checking against the patient notes, or--as in the case of a Wi-Fi tag pilot in Birmingham Heartlands Hospital--with a photo on the EPR, is still essential.