Have We Got the Right Patient? Patient Safety, Patient Identification and the Secret Life of Porters

Abstract

Rajhkumar Sivalingam, Joanne Kitchin, Peter McCulloch

Background

Several serious adverse events (SIRIs) have occurred in OUH involving porters transferring the wrong patient.  The Patient Safety Academy (PSA) were asked to identify the causes of these incidents.  They evaluated the patient transfer process in OUH using a Human Factors approach, aiming to identify:

1. the causes of PPID errors during patient transfer
2. Potential solutions.

Methods

Ethnographic observation was conducted focusing on two areas:

1. The interactions between porters, medical staff and patients
2. The types of PPID (Positive Patient Identification) sources used, how often, and by whom.

Porters were shadowed in 34 patient transfers: 12 in the main hospital and 22 in the Emergency Department (ED). Process maps and swim lane diagrams were used to analyse data.  Based on this analysis potential areas for improvement were identified, and recommendations made.

Results

We discovered that porters have no official responsibility to identify patients. The information they receive is inadequate especially in ED and when patient transfers are assigned via radio. There is no clear evidence of porters undergoing any systematic training or induction. Though nurses have responsibility for PPID, their role is not clearly defined, and in many instances not performed. Confidentiality requirements contribute to a risk of miscommunication between porter’s office and ward staff during the request for a patient transfer by phone.

Implications

Action is required to train porters in PPID and integrate it into their work, and to clarify nurse roles in PPID for transfer.  Better means of communication for transfer requests are proposed.