Hospitals must standardise patients' wristbands to reduce risk of wrong careBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39279.348843.DB (Published 19 July 2007) Cite this as: BMJ 2007;335:118
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‘Identity Wristband Friend or Foe’
Over a 12-month period from February 2006 to January 2007, the NPSA received 24,382 reports of patients being mismatched with their care and 2900 of these were directly related to identity wristbands (IWBs) (1). As a result, the National Patients Safety Association (NPSA) issued guidance endorsed by Department of Health (DoH) (2) to standardise hospital IWB use(1).
From observations of peri-operative practice we identified potential infection control and identity check risks to patient safety involving the IWBs. We referred to NPSA(1), Association of Anaesthetists of Great Britain and Ireland (AAGBI) (3) guidelines, and DoH report (2) to clarify the following questions:
Where is an ideal body location for patient identity bracelets? Should the wrist be the only option?
The best practice guidelines (1) focus on the model identifiable information including barcode technology, the human factors of the identification process and the safest material, size and shape of the IWBs. It recommends that the IWB should be applied on dominant wrist (4) and leaves it for individual NHS trusts to choose the alternative location should the wrist be unavailable or inappropriate.
The IWB is constantly handled during theatre processes for surgery with no protocol for its placement or care, other than they should be easy to clean and waterproof (4). Indeed this most vital of all tasks may be delegated to a health care assistant.
The link between intravenous access and MRSA bacteraemia is well recognised (5). The most serious health care associated infections tend to be bloodstream infections with most common risk factors being
insertion and management of intravenous access devices (peripheral and central lines) (6). In the recently published NICE guidelines (7) there is great emphasis on the strict asepsis and non-touch technique when inserting and handling venous access.
Intravenous access is frequently established on the dorsum of the hand with best practice in anaesthesia using the non-dominant side (3). Where the practitioner chooses the same side to cannulate as the IWB the proximity of the ‘dirty’ IWB and IV access is established.
For unilateral breast or upper limb surgery, the anaesthetist will use the non-operated side. In these cases, the anaesthetist may have to remove the IWB in the anaesthetic room, which does not build confidence for patients who are already anxious.
Laparoscopic techniques are increasingly used for major, lengthy surgery, which requires both upper limbs to be securely ‘wrapped in’ down their whole length. This renders the IWBs inaccessible should checks be needed intra-operatively (i.e. identity check prior to blood or blood products transfusion). The new, mandatory WHO ‘timeout’ pre-surgical identity checklist requires the IWB to be examined, which usually means delay in patient positioning until all team members are available for ‘timeout’.
Acknowledging the above real operating department scenarios, we need to consider re-siting the IWB or accept a compromise.
Whilst the NPSA recognises that there are occasions when the wristband is removed for cannulation, there is no clear care-bundle available. We have observed that when the IWB is removed, it is usually taped to the patient’s upper body or kept with the patients’ notes for the duration of the surgery. To conclude, the proximity of the IWB with the venous access device is the rule rather than the exception in the peri-operative practice.
These observations and concern at our hospital led us to culture the IWBs of 34 in-patients undergoing emergency surgical procedures that had been admitted for more that 48 hrs. 30/34 IWBs grew at least one potentially significant bacterial colony, with 21/34 cases of mixed growth. These included Staphylococcus aureus (2/34), coagulase negative Staphylococcus (11/34), Pseudomonas species (6/34), E coli (1/34), skin flora (7/34) and coliforms 1/34. The results prove that IWBs are contaminated with potentially harmful bacteria.
In our audit, 27/34 patients had a new cannula inserted and in 12/27 cases this was inserted on the same side with the IWB.
In conclusion we propose that the potential for infection of the cannula insertion site from contaminated wristbands can be removed by changing the location of the IWB to the ankle. Where limb surgery is proposed an upper body (shoulder) patch may be more appropriate.
The lower limb location has already been independently adopted by some NHS trusts such as Salisbury NHS Foundation Trusts (8) and NHS Tayside (9) but we call for a nationwide peri-operative IWB location guideline.
1. NPSA. Standardising wristbands improves patient safety. www.npsa.nhs.uk/patientsafety/alerts-and-directives/notices/wristbands
2. DoH- Review of Coding for Success implementation. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_066098.pdf
3. AAGBI. Infection Control in Anaesthesia. http://www.aagbi.org/sites/default/files/infection_control_08.pdf
4. NPSA. Guidance on the standard for Patient Identifiers for Identity bands. http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/documentatio...
5. National Confidential Study of Deaths Following Meticillin- Resistant Staphylococcus aureus (MRSA) Infection. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947311070
6. House of Commons Public Accounts Committee. Reducing Healthcare Associated Infection in Hospitals in England. http://www.publications.parliament.uk/pa/cm200809/cmselect/cmpubacc/812/...
7. NICE CG 139. Infection: prevention and control of healthcare- associated infections in primary and community care. http://guidance.nice.org.uk/CG139
8. Salisbury Health Care NHS Trust, Clare Goodyear, Patient identification Policy. http://www.icid.salisbury.nhs.uk/ClinicalManagement/OperationalIssues/Pa...
9. NHS Tayside, Sarah McLauchlan Wendy Reid, Establishing Patient Identity Policy CL/16.
Competing interests: No competing interests