2011 OPEN FORUM Abstracts
ERRORS MADE DURING POINT OF CARE TESTING: CONTRIBUTING FACTORS FROM THE BEDSIDE RESPIRATORY THERAPIST PERSPECTIVE.
Jenni Raake, Brandy Seger, Rick Amato, Scott Pettinichi; Division of Respiratory Care, Cincinnati Childrens Hospital, Cincinnati, OH
Background: Point of Care Testing (POCT) is one of the fastest growing markets. Rapid results have led to a high demand for POCT services, typically performed by the bedside Respiratory Therapist. Errors can occur during the testing process which affects results. Most commonly, errors occur with patient misidentification, and lack of knowledge or compliance regarding testing policies and procedures. Based on other studies, factors contributing to POCT errors include situations where the Respiratory Therapist has a high workload. We surveyed our Respiratory Therapists to determine if their perspective on contributing factors was due to their workload. Methods: We developed an 8 question survey using a commercially available survey website. Invitations to participate in the survey were distributed via email to the 153 Respiratory Therapists who perform POCT. Respondents were directed to the survey website to provide answers to the survey. The identity of those responding to the survey was anonymous. We received a 34% response rate (54 respondents). Results: 59% of staff report entering the wrong patient identification during POCT. While staff report 83% compliance rate with use of the patient's armband, they also report use of an open chart, a page of labels with the patient's name and ID number, or a syringe at the bedside with the patient's identification number. Reasons given for not using the identification on the patient's armband was due to legibility (54%), size of text on armband (87%), and lighting in the room (45%). Respondents indicated that patient care distractions (52%) and their overall workload (31%) were reasons for making errors during POCT. Conclusions: Based on our survey, Respiratory Therapists admit to patient misidentification errors during POCT. Methods to improve the utilization of the patient's armband such as increasing text size and legibility should be taken to reduce utilization of other non-approved patient identification sources, reducing the potential errors. Adopting automation through barcoding may also help to reduce errors at the Point of Care
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