What Would You Do?

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By AHRA Staff

May 2011–Every month, a hypothetical industry and management related situation is posted. You are encouraged to share your thoughts (in the comment box below) on how you would resolve the issue. Be sure to check out others’ responses and join the discussion.

Here is this month’s scenario:

Errors are often the result of a breakdown in the clinical process. What process redesign techniques are you introducing at your facility to ensure patient safety?


  1. We use Red Rules for patient indentifiers. Inpatients name and medicial record number are confirmed from the Radiology Request to the patients armband. Outpatients we use name and birthdate for the two identifiers. If there any discrepancies we not allowed to move forward. For the ED and IP if there is no armband we do not procceed.
    We are also beginning to report extravasations to report out quarterly.

  2. We use TeamSTEPPS. The process has been slow, and tedious, but the buy-in is getting bigger and bigger. We are seeing a decrease in fear of speaking up at all levels, and an increase in doing what is right for the patient. ie: if a nurse is not happy with the way the doctor is handling a situation, the nurse has every right to speak up, and ask if this is the appropriate care the patient should receive at that particular time.

  3. We use at least two patient identifiers, patient name and birth date. We check the arm band against the radiology request. We also check the medical record number of the patient against the radiology request. If the patient is coherrent, we ask them their name and birthdate. arm bands are used on inpatients and outpatients.

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