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Reduction of Patient Identification Errors Using Technology

Colard, David R BS, MT(ASCP)

Point of Care: The Journal of Near-Patient Testing & Technology: March 2005 - Volume 4 - Issue 1 - p 61-63
doi: 10.1097/01.poc.0000157175.75703.6a
Symposium Article

Manual entry of patient information resulted in identification errors as high as 12.4% and 400-500 unidentified blood glucose results per month for the point-of-care glucose testing in St. Luke's Hospital, Kansas City, MO, prior to December 2002. These misidentifications negatively impacted patient care and hospital billing. To address the problem, we decided to implement an automated patient and sample identification systems for the 12,000 test per month service. The Accu-Chek Inform system with barcode reader (Roche Diagnostics, Indianapolis, IN), RALS-Plus information management platform with Admission Discharge Transfer checking (Medical Automation Systems, Charlottesville, VA), and barcoded patient armbands were implemented as part of a quality improvement initiative. The barcode symbol was changed from code 39 to code 128 to reduce print width of the barcode, and the armband was placed in a protective pouch to minimize wear. Additional training was provided to point-of-care operators on the Accu-Chek Inform/RALS-Plus/barcoded armband system. Operators requiring additional instruction were identified as errors occurred. Review of the patient identification errors after implementation of these initiatives showed a significant decrease from as high as 12.4% to 0.18% per month. Also, the number of unidentifiable blood glucose results decreased from 400 to 500 to 6 per month with 18 months.

From the Department of Pathology, Saint Luke's Hospital, Kansas City, Missouri.

Reprints: David R. Colard, Department of Pathology, Saint Luke's Hospital, 4401 Wornall Rd., Kansas City, MO 64111 (e-mail:

© 2005 Lippincott Williams & Wilkins, Inc.