Center for Phlebotomy Education says new requirement is step backward for patient safety
When The Joint Commission recently changed the patient identification requirement for drawing a blood sample, one national phlebotomy leader considered it a step backward in patient safety.
“Per a revised policy issued by The Joint Commission, it is no longer required for the phlebotomist or person drawing the blood to actively involve patients by, for example, asking them to state their name,” commented Dennis Ernst, MT(ASCP), the long-serving Director of the Center for Phlebotomy Education. He’s one of the leading observers of phlebotomy trends and he’s concerned about what this means to patient safety.
“Having a patient state their name before a blood collection is a very important step in patient identification,” declared Ernst. “The Joint Commission now finds it acceptable for the phlebotomist to use the identification bracelet alone, which we all know can end up on the wrong patient. That’s disturbing to me because it’s taking a chance with a patient’s life. I think any time you dilute the requirements for patient identification, you create a possible scenario that is not favorable to anyone seeking healthcare.”
“There doesn’t seem to be any logic that supports lessening the patient identification requirement,” said Ernst, who worries that not requiring phlebotomists to verify that the person about to be drawn matches the information on their wrist band will lead to unnecessary mistakes. “It’s reported that 160,000 adverse patient events occur every year in the United States due to patient or specimen identification errors involving the lab.
“Given the frequency of these errors, it seems that asking someone to confirm their identity is a simple, positive requirement,” he added. Ernst queried The Joint Commission over this issue. He says that a representative from The Joint Commission informed him that their clients feel that it is “burdensome and unnecessary” to ask a patient to confirm his or her name.
“Given how often the wrong ID band is put on a patient, this creates a situation where patients can be misidentified and the individual performing the blood collection can be completely compliant with the Joint Commissions’ requirements,” Ernst said. “From the perspective of a laboratory, I would recommend it follow a procedure that is one step higher than the requirement of The Joint Commission for positive patient identification.
Ernst also pointed out a difference between The Joint Commission’s requirement and the protocols provided by the CSLI standards. “Where hospitals and laboratories adhere to the CSLI standard, they will automatically ask a patient to say their name. But the problem is that the CLSI standards are voluntary standards.”
There’s another interesting perspective concerning The Joint Commission’s revised new requirement for patient identification. In laboratories which use Lean and quality management methods organized around “system of prevention” concepts, it is likely their work flow requirements do require the phlebotomist or person collecting the blood sample to ask the patient to verbally say their name. After all, that simple step provides one more important safeguard against a patient identity error.