Category: Clinical Corner


Clinical Corner: Patient Identifiers

by Joe Bryowsky RN, CCRN Clinical Manager

A myriad of problems could occur because a patient was not identified correctly. The most common is medication errors but that is only the tip of the iceberg, so to speak. Other detrimental results such as wrong surgeries, wrong discharge instructions, improperly taking/giving blood or blood products and other specimens for clinical testing are just a few of the others that could occur if a patient is not properly identified.

In 2004 The Joint Commission (TJC) recognized the need for proper patient identification when it issued their very first Patient Safety Goal which is referred to as the “two Identifier Rule”. There are 2 basic parts to this rule and they are:

1.) Use at least two patient identifiers when administering medications, blood, or blood components; when collecting blood samples and other specimens for clinical testing; and when providing treatments or procedures. The patient’s room number or physical location is not used as an identifier.

2.) Label containers used for blood and other specimens in the presence of the patient

Acceptable patient identifiers can vary from hospital to hospital and it’s always best to consult the hospitals policy and procedure manual for what is acceptable at a particular facility. The most common patient identifiers are:

1.) Name

2.) Date of birth

3.) Telephone number

4.) An assigned identification number

5.) Address

6.) Photograph

7.) Social Security Number (most institutions don’t use this due to the proprietary nature)

These TJC “rules” are pretty straightforward yet regrettably not always followed, or are followed improperly. When confirming two patient identifiers with patients, it’s not enough to provide the information and have the patient confirm (the patient may be confused, hard of hearing, etc. and the patient may just confirm what you’re telling them whether right or wrong). You must ask the patient to identify themselves/provide the patient identifiers. When identifying a patient remember that the number one rule is to ask only open-ended questions. Examples of this are:

A.) Would you please state your name?

B.) Would you please state your date of birth?

C.) How are you feeling today?

If the patient is not alert and oriented, or is deaf, the patient arm band can usually be used for identification but one needs to proceed with caution with this. There have been documented cases where the name band has been either put on the wrong patient, or the wrong patient was input by admissions.


Clinical Corner: Incident Reports

by Joe Bryowsky RN, CCRN – Clinical Manager

Incident reports play an integral part in preventing, detecting and investigating medical errors. They help to maintain a safe environment for patients, visitors and employees. An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, visitor or staff member is injured or involved in a situation with the potential for injury, an incident report is required.

Examples include, but are not limited to:

  • Needle sticks
  • Falls
  • Procedure errors
  • Misuse of, or faulty equipment
  • Other types of injuries or accidents
  • Property loss or damage
  • Theft
  • Fires

Most events or errors happen because of process issues:

  • Many “little” failures lead to a “bigger” failure
  • Rarely a “person” failure

The incident  report should be completed immediately (or as soon as possible) by the employee involved or the employee giving care at the time of the incident.

When filling out an incident report remember to include only the facts. Include the full names of anyone involved and of any witnesses, as well as how, or if they were affected. Describe what you saw or heard that led you to believe an incident had taken place. Be sure to use only nonjudgmental and non- criticizing statements when filling out an incident report.

***Remember to record all clinical observations in the chart, not in the incident report.

Most hospital policies dictate not to make any mention of the incident report in the patient record but this varies widely from hospital to hospital. Always make sure you familiarize yourself with the hospitals policy before having to file an incident report.

There is a lot of controversy as to whether a patient’s attorney can request and receive an incident report and use it in a malpractice lawsuit. The law varies from state to state but most hospitals label the incident report as an integral part of the quality assurance process, which usually suffices to keep the reports from being discoverable.



Clinical Corner: HIPAA in a Nutshell

by Joe Bryowsky RN, CCRN – Clinical Manager

What is HIPAA?

In 1996 the U.S. government enacted the Health Insurance Portability and Accountability Act. This law is meant to keep a patient’s medical information private.

What constitutes a HIPAA violation?

  • Showing or sharing the information to an unauthorized person: If any health-care provider shares medical information about a patient without the patient’s consent, that is a HIPAA violation. This includes telling people about the patient’s condition, discussing the patient’s condition in public, or using the patient’s information in a medical brief without the patient’s consent. This would also apply to today’s technology which includes cell phones that take pictures, Facebook, texting, etc.
  • Excessive Views: Too many looks at a medical record or more often than needed, can constitute a violation of the law. Sometimes this happens when a patient with an abnormal condition comes into the hospital or because people are simply curious.
  • Health discrimination: Sometimes employers violate HIPAA. If an official from the company you work for reads your medical information and uses it to make a decision about you, that is a violation.
  • Improper disposal: Hospitals, Medical offices and Clinics are required to shred, and dispose of, any medical records. The violation would be against any one of these entities due to neglect if records were disposed of improperly.

These are all important points for all healthcare workers to be knowledgeable in. One of these points however is the one most frequently overlooked and that is the first bullet point above:

Showing or sharing the information to an unauthorized person: Under the privacy rule, a healthcare provider may “disclose to a family member, other relative, or a close personal friend of the individual, or any other person identified by the individual,” the medical information directly relevant to such person’s involvement with the patient’s care or payment related to the patient’s care.

Uses and disclosures for involvement in the individual’s care and notification purposes are clearly permitted. Right?

Here’s the catch, and it’s the one that most healthcare workers fail to think about at one time or another. The rule states that if the patient is present, the healthcare provider may disclose medical information to such people if the patient does not object. If the patient is unable to agree or object to disclosure because of incapacity or an emergency circumstance, the covered entity may determine whether the disclosure is in the best interests of the patient.

How many times have we gone into a patients room, friends and/or family members are present, and the patient asks us a question about their care, treatment modalities, diagnosis, etc.? Just about every day, right? And how many times have we just answered their question and thought nothing about it? After all that’s just part of delivering excellent patient care, right?

Think again. HIPAA violation!! All healthcare workers must remember to always ask the patient if it is OK to share that information in front of anyone in the room that is not a healthcare worker who is directly involved in the patient’s care.


Always remember: “Protect the patient and protect yourself”!


For more information go to:



Clinical Corner: CRE’s (Carbapenem-resistant Enterobacteriaceae)

by Joe Bryowsky RN, CCRN – Clinical Manager

There’s been a lot of talk in the news lately about CRE’s. This was precipitated when Dr. Thomas Frieden, Director of the CDC, made the statements that “CRE are nightmare bacteria” and “Our strongest antibiotics don’t work and our patients are left with potentially untreatable infections”.

But what are CRE’s and what precautions should healthcare workers take in reducing the spread of CRE’s?

CRE, which stands for carbapenem-resistant Enterobacteriaceae, are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. Enterobacteriaceae are a family of more than 70 bacteria which share the characteristic of being gut-dwelling (entero). They include Klebsiella, Salmonella, Shigella and E. coli. Carbapenems are a “last-resort” family of antibiotics (imipenem, meropenem, doripenem and ertapenemen.) which are used against these bacteria when they have become resistant to other drugs.

Healthy people usually don’t get CRE infections. Infections caused by CRE most commonly occur in people who have:

  • Chronic medical conditions
  • Recent prolonged stays in healthcare settings
  • Invasive devices such as ventilators, IV catheters, urinary catheters
  • History of taking certain antibiotics for long periods of time

Just when we thought super bugs like MRSA (methicillin-resistant staphylococcus aureus), VRE (vancomycin-resistant enterococci) etc. were bad enough with about a 20% mortality rate, we’re now seeing an increase in CRE’s, with about a 50% mortality rate, becoming ever more present in our healthcare settings!

Am I at risk in taking care of patients with carbapenem-resistant Enterobacteriaceae?

This type of infection generally occurs in more sick patients following long courses of broad spectrum antibiotics. As a healthy individual, you are not at risk of “catching” this type of infection. However, without taking proper infection control precautions, you are at risk of spreading carbapenem-resistant Enterobacteriaceae to other patients.

How can carbapenem-resistant Enterobacteriaceae infections be prevented in the healthcare


To prevent spreading CRE infections between patients, healthcare personnel must follow specific

infection control precautions (See: Guideline for Isolation Precautions: Preventing Transmission of

Infectious Agents in Healthcare Settings 2007 at

All patients colonized or infected with CRE should be placed on contact precautions. These

precautions include wearing gowns and gloves when they enter carbapenem-resistant



Clinical Corner: New AHA Stroke Guidelines Part 2

by Joe Bryowsky RN, CCRN – Clinical Manager. This is the second part of Clinical Corner: New AHA Stroke Guidelines Part 1

Points to Ponder:

• Worldwide, stroke is the second leading cause of death, responsible for 4.4 million (9 percent) of the total 50.5 million deaths each year.
• Stroke is the No. 3 cause of death in the U.S., behind heart disease (with which it is closely linked) and cancer.
• Stroke affects more than 700,000 individuals annually in the United States (approximately one person every 45 seconds). About 500,000 of these are first attacks, and 200,000 are recurrent attacks.
• Someone in the U.S. dies every 3.3 minutes from stroke
• Stroke is the leading cause of disability among adults in the U.S.
• More than 4 million people in the United States have survived a stroke or brain attack and are living with the after-effects.
• Four out of five families will be somehow affected by stroke over the course of a lifetime.

Remember: easy way to remember the sudden signs of a stroke:
• Face drooping: Does one side of the face droop or is it numb?
• Arm weakness: Is one arm weak or numb?
• Speech difficulty: Is speech slurred, are you unable to speak, or are you hard to understand?
• Time to call 9-1-1: If you have any of these symptoms, even if the symptoms go away, call 9-1-1 and get to the hospital immediately.

For more information regarding new stroke guidelines please visit:


Clinical Corner: New AHA Stroke Guidelines Part 1

by Joe Bryowsky RN, CCRN – Clinical Manager

On January 31, 2013 the American Heart Association announced the updated Guidelines for the Early management of Patients with Acute Ischemic Stroke.The new recommendations replace the guidelines last issued in 2007.

While some of the guidelines from 2007 remain the same other guidelines have been added, changed or eliminated.

The revised and new recommendations:

• Supports aggressive treatment of acute stroke with IV tPA (Tissue plasminogen activator)

• Shows evidence that patients benefit from the development of stroke systems of care. (EMS along with Acute Stroke Ready Hospitals, Primary Stroke Centers (PSC’s), and Comprehensive Stroke Centers (CSC’s)

• Recognizes that the addition of telemedicine
(telestroke) has further expanded the radius of stroke care delivery

• Recommends that EMS bypass hospitals that do not have resources to treat acute stroke

• Highlights pre-hospital notification by EMS

• Reiterates that only a limited number of laboratory and radiologic tests are required before administering IV tPA (blood glucose check and non-contrast enhanced CT or MRI)

• States that door to tPA bolus time interval of 60 minutes or less maximizes benefits of IV tPA

• Suggests that intra-arterial mechanical thrombectomy has emerged as a promising therapy for a subset of stroke patients that are identified with advanced neuroimaging

• States that tPA can now be considered for a larger group of patients, including some who present up to 4.5 hours from stroke onset

These guidelines also address the lack of clinical evidence in the following for the treatment of acute stroke:

• The use of devices to augment cerebral blood flow
• Drug induced hypertension
• Volume expansion
• Hypothermia

Continue reading part 2 of Clinical Corner: New AHA Stroke Guidelines

For more information regarding new stroke guidelines please visit:

Page 4 of 41234