'Two patient identifier' rule works!

Three patients a day, on average, receive blood products in the infusion suite at the Hallmark Health System Hematology and Oncology Center in Stoneham. Most patients register and have lab work done on one day and come back the following day to receive the infusion. This gives the lab time to do an analysis, send the information to the blood bank at Melrose-Wakefield Hospital to prepare the appropriate product, and deliver it to the infusion suite for administration.

As always, that process was in place on a Thursday in June when a patient was seen by her hematologist/oncologist at the center and it was determined that she needed a blood transfusion.

The following day, the patient came back for her transfusion. She was asked her last name and date of birth as part of Hallmark
Health’s standard “two patient identifiers” protocol to ensure patient safety for all procedures. The date of birth the patient gave didn’t match what was on the blood product she was about to receive.


“This initiated a hard stop from a safety point of view,” said Glenn Davis, RTTR, oncology operations manager. “We then verified the patient’s date of birth with her ID.” The patient’s registration information was updated to match her photo ID and new orders were generated for her blood work and transfusion. “It is essential that all patient identifiers match all along the way – from orders to testing to treatment delivery,” said Davis.

None of the members of the treatment team that day had ever experienced a discrepancy with a patient’s date of birth.

“The patient’s transfusion was delayed, but patient safety is always a priority,” he added. “This incident helped reinforce with the team why the ‘two patient identifier’ rule exists and that when the policy and procedure is followed, it works.”


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