ID arm bands on the wrong pt. 3X!

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........

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.

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.

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.