ID arm bands on the wrong pt. 3X!

  1. can anyone tell me how on earth can anyone place the wrong id arm band on a pt?

    this is the 3rd time in the last 4 months that this has happened on our unit. four months ago when we got a new rn, she scanned the pt's bracelet, his name came up on the computer saying is this the right pt? of course she clicked yes. gave him his meds and went on to the next pt in the same room. a na came into the room and said the pt's name she said that isn't mr. so and so? he said no it's... mr. so and so. well there's a big med error! the poor thing was on orientation. she was so infuriated that she quit.

    today the head nurse said before you all leave i want to ask you a question. her question was,"how does one place a wrong id band on a pt 2x?" we kinda looked at each other and i said, "you don't unless you don't know them. but i would hope you would ask someone else that does know them to identify them." well it turns out that on friday (when i was off-thank you) two new arm bands were placed on the wrong pts. no one will confess that they did it, and it was another new nurse who found them. now i'm thinking if no one will confess, could it be that someone put them on deliberately. is that possible??? and why would you want to do that and put the pts at risk and cause a new person to make a med error like the last new nurse we had? my question to the head nurse was, "how can you not see the name on the bracelet while you're putting it on and if you knew the pt, knew that it was the wrong one?" she replied, " i don't understand either, but someone had better come up with some answers because now i have to answer to so and so!" (who is the clinical coordinator director of our ltc facility) it really bothers me that someone could be that stupid in plain english to put the wrong arm band on one person never mind two!!! unless it was done on purpose... sorry, i'm just venting
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  2. 8 Comments

  3. by   oramar
    I doubt if there is a conspiracy here. Most likely someone or several someones are being careless. I have seen wrong arm bands on people also. Once I was covering for an ICU nurse. In report she said MR Brown was in room 1 and Mr. White was in room 2. Please cover Mr. Brown in room 1 for insulin at noon. When I went into do it I realized the arm bands said Mr. White was in room 1 and Mr. Brown was in room 2 which did not jive with report or records. Both patients were tubed and unconcious. I had to call her back from lunch. After an investigation by managment it appeared incorrect arm bands were placed in ER when two unconcious patients were tubed at the same time. It was never discovered who did it but at our hospital non licensed people usually did arm bands and it was a recurring problem until we changed that policy. By the way we had our suspicions that a certain admissions person was making the same mistake over and over again but how do you prove it when they deny it. This person had a reputation for being sloppy and lazy and complaining constantly she had to much to do. Some people thought she screwed things up on purpose as a way to get her work load lightened. I think she just was a careless sloppy person. Anyway, it resulted in another non technical task being heaped on nursing.
  4. by   RNforLongTime
    The hospital that I work at has a policy that namebands be checked each shift and there is a place on our nursing care plans to document that this was done.. I work in a smaller facility and we don't have a scanner system but when i am admitting a patient I ask the pt are you Mr. Jones and is your birthday such and such a date(I am reading this info off of the name band that I will be applying) and as long as th patient is alert and oriented this works ok. Now for disoriented patients--I double check the information that is sent up with the patient from the ER. I have yet to find the wrong nameband on a patient. That is why we check the namebands once a shift and make the changes if necessary.

    Kelly
  5. by   kitty=^..^=cat
    at my facility, the registration clerk who keys in all of the patient's information is responsible for initiating the first armband before the patient even reaches the unit. if the patient comes from er, it's the same process -- the clerk puts on the armband. extra armbands are placed in the patient's chart in case the original has to be cut off for an iv or something.
  6. by   P_RN
    KittyCat you have an ideal situation. I will add that asking someone "Is your name so-and-so?" can be a LOADED question.

    I have had patients answer to anything from Chubby Checker to the Queen of England....they would answer to anything!! Best to ask what is their name.....what is their b-day...etc. Then if you still have doubts then by ALL means DON'T give the medicine.

    Our hosp. was terrible for sending patients to the floor with the arm band paperclipped to the front sheet. That was as a result of Nursing complaints about armbands being on the wrong patient.....so admitting quit putting ANY bands on. ......

    You all are familiar with LET NURSING DO IT. IT ONLY TAKES A SECOND TO DO!!

    And then there were the post-op patients who arrived from PACU with NO armband.....cut off of course....and "nobody knows who did it." Not just the nameband either...but the blood ID band....so they had to be TXM all over again before they could get a transfusion........
  7. by   NRSKarenRN
    Interesting thought. Who IS responsible? ALWAYS the licensed professional per courts, states and JCAHO.

    I was involved in a blood transfusion incident because of NO ARMBAND on a patient. I had been called in early, and was asked to verify blood for another nurse administering the it. All paperwork checked: patient ID was labeled for ICU bed, had overheard this patient was transfered at 3 PM from ICU, on vent and unable identify herself. RN in charge of patient idenfiied paitent as same person as blood forms. I signed even though our form stated that ID band checked. 4 hrs later when time to administer 2nd unit, she discovered that this unit had different patients name. As newer RN, she asked me what to do??? I quickly checked patient VS stable, thankfully given O+ blood. All could have been covered up by accidentally not placing transfusion form on chart. I couldn't live with my conscious and made her file an incident report. No one could believe, I was involved in incident, as known for thoroughness. She was suspended for a day. I was given a repremand and counseling with Clinical specialist and next transfusion cosigned by supervisor. Well one week later, another patient transfered to unit needing blood without ID band. I refused to co-sign and made transfering RN come back to unit, identify patient and place armband until new RM # band arrived from admission dept.
    This is a clerks task---problem entails when wrong ID. NURSES need to be final check that the ID is correct. I've even made ER staff come to floor to identify patient if sent without band after that ( if sent with just transporter). ONCE was enough.
  8. by   georgia nurse
    NRS KAREN-I WAS STARTLED BY THE CONSEQUENCES OF THE BLOOD INCIDENT. SUSPENSION FOR THE ONE NURSE? IS THIS A COMMON OCCURENCE FOR MISTAKES OR WAS THIS ONE JUST DEEMED SO "SENTINEL" AS THEY SAY?
  9. by   P_RN
    GA Nurse. Hi.

    Not NrsKaren obviously. The consequences of the incident would of course depend on the rules and procedures of the facility.

    However I believe that the new nurse did get an equitable "punishment." The fact that she got caught up in a cascade of identification errors was probably why she "only" got the one day suspension.

    This happened at my hospital with an RN with 30+ years experience. She gave Patient A the autologous blood stored for Patient B. The types were the same and there was no transfusion reaction.

    She was suspended for a week without pay. She was reported to the Board of Nursing and had an investigation by them. That left a note in her licensing file. She was asked to leave the floor, not to work without supervision for 3 months. She finally got a position in a non patient care area....but with a reputation preceding her.

    The policy could have been construed to be immediate firing. Identification is VERY important. In the case Karen reported,
    I think the transferring nurse should have also been included.

    And how did the new nurse GET the unit from the blood bank WITHOUT proper identification. We had to have the order in the computer, the addressograph plate, the type and cross match bracelet, another nurse to be physically present when the blood was hung. Otherwise NO transfusion until everything correct.
  10. by   NRSKarenRN
    This event happened in 1985 before computers on floors. All paperwork cliped together from ICU including ID band from blood bank ( had just come up from blood bank) awaiting unit clerk putting paperwork on chart and new plate for patient with correct room number. I had assignment on other side of hallway ond only heard that patient was ICU transfer; didn't realise RN had another new patient ALSO transfered from ICU to our telemetry unit. Memory is hazy but I think transfering RN also had disciplinary action. There is no excuse for a patient NOT to have an ID band placed in the ER (hand written) and a stamped one can be added latter. i had not routinely checked on walking report that patients i received had ID band on, but you better believe I did after incidnet and would let prior RN leave til she placed band on patients arm. It was a wakeup call for our entire floor and the hospital--- nurses had gotten too lackidasical about it.

    In todays world it would be a sentinel event and depending on circumstances reported to SBON. Check out "Rising premmiums in PA" thread under nursing activism, talks about transfusion reaction at University of PA Hospital. NO STAff thought to check blood bag as patient was coding, massive hemolytic reation!!!!! It can and will happen again if harried staff fail to follow procedures.

    I started in home health shortly after that and it is a problem here too as I had a set of older twins who thought it was "fun" to pose as the other when relief RN's would visit . No arm bands here to check, just the patients word that they are who they say.

    RE above post: Imperative that you get the patient to tell YOU their name and date of birth; too many would agree to anything you say, especially if elderly.

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ID arm bands on the wrong pt. 3X!