Safety Lesson Learned: Turning on the Lights

The need for correct patient identification outweighs all other considerations when giving care to patients.

By Marty Lewis-Hunstiger RN, BSN, MA

Lessons Learned depict situations of risk from across the country. Events described did not necessarily happen at Children’s Hospitals and Clinics of Minnesota. Details have been changed and/or are a composite. The goal of studying these cases is to prevent similar occurrences.

Scenario: A 4-year-old child with pneumonia was admitted to a pediatric unit at midnight. He had been sick for several days and his family was exhausted. The doctor ordered IV antibiotics every 6 hours and nebulizer treatments every 4 hours. The mother arranged to sleep in a chair bed in the room with her child. A teen-age patient with a very similar name was in the room next door.

When the nurse came to give the 2 a.m. antibiotic, he turned on the light to check the child’s ID band. The mother awoke, and complained about the interruption, saying, “What my child needs right now is sleep” The nurse explained that he had to make sure the right patient was receiving the right medication.

At 4 a.m. the respiratory therapist came to give the nebulizer treatment. She had heard about the mother’s complaint so tried to read the child’s ID band with a flashlight but was unable to see it. She turned on the light, and found that the medication she was about to give was for the patient next door, with a dose twice as large.

Discussion: Hospitals are often not the best places to get a good night’s sleep. Barriers include unfamiliar noises from monitors and pumps; conversations in hallways; frequent interruptions for vital signs, medications, and treatments, and lights turned on at all hours. There are things hospital staff can do to help patients rest and sleep:

• Avoid unnecessary conversations in patient care areas; when talk is necessary, keep voices quiet.
• Group cares and treatments to minimize interruptions to sleep.
• Use monitors and pumps optimally to minimize alarms.

Caregivers may be reluctant to turn on lights in a patient’s room in the middle of the night. In pediatric settings, it is often family members staying with the child who object to turning on the lights. However, the need for correct patient identification outweighs all other considerations when giving care to patients. This includes visualizing the patient’s ID bracelet before all medications, treatments, and procedures.

Many hospitals, including Children’s of Minnesota, are implementing bar coding systems to make sure that medications that are dispensed and administered match the patients they are meant for. Bar coding systems make medication administration safer only if they are used properly, every single time. These systems eliminate visual misreading of patient names and ID numbers, but will still necessitate locating and scanning the ID band as well as assessing the patient’s readiness for and response to the medication.

Anticipated Improvements: Caregivers will be supported in using all means needed to perform effective patient identification and assessment, even in the middle of the night.