Building bridges one bar code at a time: laboratorians and nurses pursue patient ID system

Medical Laboratory Observer, Sept, 2004 by Melody Botterbusch

Data management for point-of-care (POC) testing is designed to save time and money and to improve accurate posting of results to the patient chart. Many "puzzle pieces" must fit, working together to capture and interface POC data. In York, PA, the York Hospital's (York's) Sure Step FLEXX glucose interface system held much promise until a puzzle piece fell out of place in January 2001.

Before ythe use of the glucose test system, York's data was entered manually into the laboratory information system (LIS). But now for the first time, POC results could be captured electronically. The new meter was equipped with a bar-code scanner. Operators wore a bar-coded employee badge with an ID number assigned by the hospital's security department. Patients wore an armband that had a bar-coded financial number (FIN). To perform a POC glucose test, the operator would first have to be identified using the bar-coded image on the employee ID badge. Then the armband of the patient would be scanned to capture the image of the FIN.

At first, implementation went smoothly. Shortly thereafter, a trend started to emerge. The POC department began to generate billing errors because testing was being done on discharged patients. How could this be happening? To the hospital staff's dismay, the bar-coded image on the patient armband was fading, smudging, and smearing from normal patient use almost immediately after application. The operators were scanning something other than the bar-coded armband. Nothing protected the label from moisture or mechanical deterioration.

The volume of errors warranted making "POC billing errors" a performance improvement (PI) indicator. Meanwhile, frustrated operators began to scan just about anything except the patient armband in an attempt to capture an image that would allow them to continue to perform the bedside glucose test--the dawn of a habit known as the "workaround."

Some assembly required

In an effort to correct the problem, a different armband was requested. This second armband had a plastic sleeve. The armband label that was previously attached to the outside of the band now was placed on a card-stock insert, slipped into the plastic sleeve, and then sealed. "Some assembly required" was our new motto--but at least now, the bar-coded image was protected from deterioration. Or so it was thought. Again, it did not take long to discover that the label inside the plastic sleeve also faded, just a little more slowly than it did when placed outside of the armband.

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The POC department promoted scanning of the armband for patient identification. When the armband failed to scan, the nursing staff was encouraged to replace it with a new band--a time-consuming chore for the busy nursing staff. The shortcoming of the system was obvious, but laboratorians and nurses were powerless to bring about a change until the POC department conducted a Q-Probe on one of the more problematic and high-volume testing units.

Q-Probe is part of the Q-TRACKS program designed by the College of American Pathologists to provide continuous quality-improvement monitors for hospital laboratories. From York's study of 161 patient armbands, results showed that 11% were illegible and could not be scanned by the FLEXX meter. Operators were scanning creative alternatives for patient identification. It became evident that yet another new armband system had to be found. York's POC department studied practices and procedures from other healthcare institutions and questioned their personnel about what system was being used for patient identification. York Hospital discovered that not many institutions utilized a bar-coded armband. Therefore, the staff had to blaze its own trail in the bar-code wilderness.

The lab-nursing partnership is born

Up to this point, the lab (POC) and nursing staff were somewhat at odds. The lab wanted better compliance with patient identification for glucose testing; nursing just wanted hassle-free testing. Both sides got a chance to air frustrations when they were invited to participate in a failure mode effects analysis (FMEA) team. The FMEA process was formed to address patient-safety issues. JCAHO requires the FMEA be employed for high-risk tasks. Because the POC department used billing errors directly related to failing armbands as a PI indicator, enough data existed to prompt York's patient-safety committee to recommend the armband process be added to the FMEA. A multidisciplinary FMEA team formed in January 2003 included nurses from three different types of in-patient units, the laboratory operations manager, phlebotomists, and the POC coordinator.

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During those FMEA meetings, frustrations were vented in a productive, controlled environment. Every conceivable way the patient-identification process failed was recorded, with the goal of providing interventions to prevent the continuation of those failure modes. What developed was an alliance or partnership between the lab and nursing. As Janet Werner, LPN at York Hospital, says, "The relationship that developed between the lab and the nursing staff while working on the FMEA was remarkable. Without the caring personnel from both departments, the project would not have been a success. It took much patience, persistence, and time from them to accomplish this mission, and they gained much knowledge from each other."