Patient and family education for fall prevention: involving patients and families in a fall prevention program on a neuroscience unit.

A neuroscience unit in an acute care hospital reported the highest number of falls among the inpatient units. Patient and family education for fall prevention on this unit was added to an existing multifactorial fall prevention program. Through this project, a new fall prevention poster was developed with patient, family, and staff involvement and disseminated throughout the hospital. Using the Plan-Do-Study-Act model to evaluate the project, there were no fall among the patients educated on fall prevention.

Reducing medical errors through barcoding at the point of care.

Medical errors are a major concern in health care today. Errors in point-of-care testing (POCT) are particularly problematic because the test is conducted by clinical operators at the site of patient care and immediate medical action is taken on the results prior to review by the laboratory. The Performance Improvement Program at Baystate Health System, Springfield, Massachusetts, noted a number of identification errors occurring with glucose and blood gas POCT devices. Incorrect patient account numbers that were attached to POCT results prevented the results from being transmitted to the patient's medical record and appropriately billed. In the worst case, they could lead to results being transferred to the wrong patient's chart and inappropriate medical treatment. Our first action was to lock-out operators who repeatedly made identification errors (3-Strike Rule), requiring operators to be counseled and retrained after their third error. The 3-Strike Rule significantly decreased our glucose meter errors (p = 0.014) but did not have an impact on the rate of our blood gas errors (p = 0.378). Neither device approached our ultimate goal of zero tolerance. A Failure Mode and Effects Analysis (FMEA) was conducted to determine the various processes that could lead to an identification error. A primary source of system failure was the manual entry of 14 digits for each test, five numbers for operator and nine numbers for patient account identification. Patient barcoding was implemented to automate the data entry process, and after an initial familiarization period, resulted in significant improvements in error rates for both the glucose (p = 0.0007) and blood gas devices (p = 0.048). Despite the improvements, error rates with barcoding still did not achieve zero errors. Operators continued to utilize manual data entry when the barcode scan was unsuccessful or unavailable, and some patients were found to have incorrect patient account numbers due to hospital transfer, multiple wristbands on a single patient, and selection of expired account numbers from previous hospitalizations when printing the barcoded wristbands. Barcoding can thus improve the incidence of identification errors, but hospitals need to take additional steps to ensure successful barcode scanning and to verify that patient wristbands contain correct information. Implementation of patient barcoding was successful in significantly reducing identification errors with POCT, improving patient care, and enhancing interdisciplinary communication.