Armstrong Institute for Patient Safety and Quality: Patient Experience

How might we improve the patient identification system to reduce patient misidentification?

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Illustration by Jayne Chartrand

Project in a Nutshell
Streamlining patient identification experience for nurses to ensure consistent accuracy.

After switching to a new Electronic Medical Records system at JHU Hospitals there was an uptick in nurses printing duplicate patient ID bands. Duplicates were brought with nurses on rounds or posted in accessible areas of a patient’s room to avoid scanning the wrist directly at a patient’s bedside. This saved nurses the back and forth steps between the medicine cabinet, computer, and medicine dispenser located down the hallway, however when there isn’t a singular wristband on a patient’s body it can result in incorrect medicine type or errors in dosage and frequency.

Project Team
PartnerArmstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, Matt Barr, Jayne Chartrand, Mimi Yang, and Molly Reddy, Faculty Rhonda Wyskiel, Mike Weikert, and Thomas Gardner


Based upon our research insights our goal was to create conditions for nurses to follow newly required procedures and to streamline processes in an effort to save them steps, cut back on repetitive motions, and incentivize proper identification of patients every time. Hopkins’ dedication to patient-centered care was evident in our observation, so we also wanted to focus on shared experiences between patients and nurses in our solutions.

Proposed Interventions
We presented four prototypes of interventions that fell in different spots on the feasibility of implementation spectrum:

Smartwatch utilizing RFID technology: Nurse wears an RFID band that is able to identify patient’s RFID band and medication (the swipe motion automatically sends this information to system, which sends approval/refusal signals to the nurse’s watch interface). Benefits include removing the stigma of the patient band and allowing patients to sleep during interaction.

Mobile Device: Nurses already carry phones, but they are not smartphones. We suggest nurses be provided with smartphones that can scan ID bands, and walk through the patient medication approval process from their phone screen.

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Illustration by Jayne Chartrand

Redesigning “home computer station”: Simply putting the ID band scanner and computer physically closer to the patient. The redesign we proposed creates a space for the nurse to more conveniently administer medication, while allowing for the system to be easily moved aside if needed.

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Rendering by Mimi Yang

Rebranding: We proposed changing patient ID band to “Patient Safety Band.” We also imagined building a brand around the Patient Safety Band through visual messaging that is comical, and creates a sense of curiosity and confidence.

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