Wristbands as aids to reduce misidentification: an ethnographically guided task analysis

Wristbands as aids to reduce misidentification: an ethnographically guided task analysis

ANDREW F. SMITH¹, KATE CASEY², JAMES WILSON ² AND DENIS FISCHBACHER-SMITH³

¹Patient Safety Research Unit, Royal Lancaster Infirmary, Ashton Road, Lancaster LA1 4RP, UK, ²Royal Lancaster Infirmary, Lancaster, UK, and ³Centre for Health, Environment, Risk and Resilience, Business School, University of Glasgow, Glasgow G12 8QQ, UK

Address reprint requests to: Andrew F. Smith, Patient Safety Research Unit, Royal Lancaster Infirmary, Ashton Road, Lancaster LA1 4RP,

Accepted for publication 4 July 2011[unique_solution]

Abstract

Objectives. Wristbands are recommended in the UK as a means of verifying patient identity but have been little studied. We aimed to document how wristbands are used in practice.

Design and participants. Task analysis of wristband application and use, drawing on qualitative analysis of workplace obser-vation of, and interviews with, clinical and non-clinical staff.

Setting. Two acute district general hospitals in northern England.

Results. Our findings indicate high levels of awareness amongst clinical staff of local and national policies on wristband use, but some ambiguity about the details therein. In contrast, non-clinical staff such as ward clerks and porters were less aware of policy, although their actions also expose patients to risks resulting from misidentification. Of seven subtasks identified by the task analysis of wristband application and use, three appeared to offer particular opportunity for error. Making the decision to apply, especially in emergency patients, is important because delay in application can delay correct identification. Advance preparation of wristbands for elective admission without the patient being present can risk erro-neous data or misapplication. Lastly, utilization of wristbands to verify patient identity was greater in some clinical circum-stances (blood transfusion and medication administration) than in others (before transferring patients around the hospital and during handovers of care).

Conclusions. Wristbands for patient identification are not being used to their full potential. Attention to detail in appli-cation and use, especially during handover and transfer, and an appreciation of the role played by ‘non-clinical’ staff, may offer further gains in patient safety.

Keywords: patient safety, patient identification, wrist bands

International Journal for Quality in Health Care vol. 23 no. 5

• The Author 2011. Published by Oxford University Press in association with the International Society for Quality in Health Care;

perspective on failure—where there is a recognition that it is the interaction between elements of the system that can give rise to failure, rather than simply being seen as a function of the actions of individuals [12, 14 –19]. Wider factors influencing events at the system level include, but are not limited to, issues relating to design, communication and information transfer (at handover), culture, latent and active errors, management style and training [15, 17 – 28]. Further, following a number of high profile ‘adverse events’ [29 – 33], with their substantial human and financial cost, the issue of patient safety has emerged as a problem for healthcare policy-makers in several countries and across the range of medical disciplines and activities [9 – 12, 28, 34 – 36].

One area that remains key to the management of adverse events is the process of checking wristbands at the bedside. This can be seen as an important process in the interaction between the patient and healthcare staff, as it not only has the potential to give rise to errors further down the chain of events, but can also act as a point where previous errors can be detected and put right. Wristbands are a frequently used method of identifying patients. Common hospital policy in the UK is to ask the patient to wear a wristband carrying details of his/her name and other information to confirm his/her identity. However, this is not completely effective in eliminating misidentification. Wristbands can only work if the patient consents to wearing one, if information is accurately entered onto them initially, and crucially if healthcare pro-viders use wristbands in their checking processes. Mismatching errors can still occur if patients do not wear a wristband or if the wristband does not carry reliable and unique identifiers. Given that there is specific guidance on the use of wristbands for healthcare staff, we set out to explore why wristbands are not used to their full safety potential.

The purpose of this study was to assess how the process of bedside checking and, in particular, the verification of identity using wristband information, are built into routines of healthcare work at the ‘sharp end’ and how these relate to formal guidelines and procedures issued at managerial level to govern these activities. The paper is based on an ethno-graphic study of the processes around bedside checking and the use of wristband-based information as a means of ensur-ing patient safety on wards. (The empirical data for the project were collected within the approved frameworks set out by both the NHS and University research ethics frame-works. Full approvals for the study were obtained and those staff who were interviewed as part of the research signed consent forms.)

Methodology

The research used two streams of analysis, a task analysis to explore the functional aspects of the checking process and an ethnographic part (observation and interview) aimed at eliciting staff perceptions and other contextual factors

Task analysis of wristband use         †              Patient safety

influencing the process. The task analysis provided a means of allowing participants to identify the main elements of their work-related tasks and to do so in a structured manner. This was enhanced firstly by direct observations of staff on the ward, paying particular attention to the manner in which they interacted with patients and their use of wrist-band information, and secondly by in-depth interviews with staff, focused particularly on their perceptions of the likely ways bedside checking acts, or fails to act, as a system defence.

The ethnographic element of the research not only pro-vided basic data for incorporation in the task analysis, but also enabled a more subtle understanding of how prac-titioners understand safety-related aspects of patient identifi-cation. Ethnography is, typically, considered as small-scale social research that is carried out in everyday settings, using a range of methods to focus on the meanings of individ-uals’ actions and explanations rather than their quantifi-cation [37]. The aim is to build up a picture of the phenomena under study which ‘makes sense’ [38, 39] to participants but which also allows, along with other quali-tative approaches, for the inductive development of more general theories [40]. Thus, it is suitable for situations which are less amenable to quantification and where discre-pancies between ‘official’ discourse and informal practice may be in play.

Task analysis

In broad terms, task analysis is a functional approach to knowledge elicitation, which involves breaking down a problem into a hierarchy of tasks that must be performed [41, 42]. Thus, it offers a methodology for examining the actions or cognitive processes involved in a given work activity [43]. It has been used in the healthcare context to map errors in the process of giving general anaesthesia [27], in an intensive care unit [44] and in the analysis of clinical pathways [45]. This begins with a general task goal (for example, ‘apply wristband’) and breaks this down into the subtasks and operations that must be performed in order to achieve the main goal. It includes the definition of the objec-tives of the task, the procedures used and any actions and objects used. The end result is a hierarchy of task steps that represent the behaviours that must be executed in the per-formance of a task.

In our study, we planned to use such a hierarchical task analysis [46], and also to employ, as an analytical framework, a modification of the systematic human error reduction and prediction approach (SHERPA) [27]. Specifically, we excluded attempts to estimate probability of occurrence of a particular error, or its criticality. Estimates of probability can be quite problematic [27], and with respect to criticality, we believe that an error in any of the subtasks could easily result in a critical event, whose severity is likely to depend not on the subtask but on the clinical context in which the error takes place. This facilitates the identification of errors that could occur, and of the points during the task at which they might occur. We aimed to break down (decompose) relevant clinical

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activities into their constituent subtasks and operations [41, 43] as shown in Box 1.

Box 1 Generic steps in tasks analysis

• Break down the primary task into a number of sub-tasks—usually between four and eight. These sub-tasks will be specified in terms of their objectives.

• Map out the subtasks into a layered diagram to ensure that the whole task is accounted for.

• Decide on the level of detail for decomposition (task flow diagrams to be used as necessary.)

• Continue decomposition process to produce a written account as the diagram is constructed. Note redundant checks and errors committed earlier in the process of care, which only become evident at this point.

• Present the analysis to someone who has not been involved in it but is familiar with the task, to check consistency and validity.

Intelligence gathering. Background material to support the task analysis was collected from a literature review as well as the observations and interviews. The literature identified was drawn from a variety of published sources. An assessment of published peer reviewed journal articles was supplemented with both ‘grey literature’ along with material published in official policies and guidance. The aim of this review was both to capture and gain an understanding of the processes around the use of wristbands as a defensive element in patient safety and to ground this in a broader assessment of ward-based errors in general, as well as an understanding of existing ‘good practice’ for risk minimization on the ward.