To improve the patient identification process for neonates and to eliminate patient identification errors, resulting in safe passage for the patient. The lack a barcode on the infant arm band makes it impossible to scan the patient prior to procedures. As a result, staff will often scan the chart, which may lead to patient identification errors.

Proposed change:

To securely and safely place an identification band on each infant so that it could be easily seen, scanned without disturbing the infant and be consistently used to identify the infant. Considering skin integrity, infant size, access, environment and ease of application we decided to place an adult band adjusted to fit our barcode on the monitor leads. Leads remain on the infant for the duration of the hospital stay.

Implementation, outcomes and evaluation:

The “trimmed” identification band with the barcode is attached to the lead wires before the leads are placed on the infant. The band will stay between the infant and the cable juncture, which lies outside the infant nesting area. This allows the label to be scanned and patient identification can be made without disturbing the infant.

Prior to implementation, identification errors were erratic, and often exceeded those of the hospital as a whole. Since implementing the new identification system in the NICU, patient identification errors for NICU admissions were reduced to zero for a 4 month period.

During the following month one error was discovered as a result of failure to follow the new identification procedure. Retraining and reinforcement continues.

Implications for nursing practice:

Nurses were given additional educational information regarding the importance of scanning the “baby” rather than the “chart”. Nurses and respiratory therapists (RT) were also educated regarding the importance of labeling all specimens at the bedside, and RTs were instructed to refuse specimens, specifically blood gases, that were not properly labeled.

Keywords:

Identification, NICU, errors, safety