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Affiliations

Christ Medical Center

Presentation Notes

Quality Improvement poster presented at Transforming Practice: The Intersection of Technology and Nursing Excellence; Advocate Health Nursing Research and Professional Development Conference 2025; November 12, 2025; Virtual.

Abstract

Background: Lack of staff participation in verifying correct patient in conversations via phone or in-person has led to an increase in patient safety events within our site.

Local problem: While receiving telemetry monitoring, a patient experienced sustained bradycardia (slow heart rate). When the concern was initially escalated to the care team, there was confusion regarding which patient was experiencing the clinical decline. The lack of use of the high reliability tool read/repeat back and patient identifiers lead to a delay in escalation to the clinician and a clinical intervention delay. Ultimately leading to a major safety event.

Method: The safety event was brought to the Professional Governance Council (PGC). The PGC created the initiative “Call, Check, Connect”. Using this patient identifier the goal is to verify patient first/last name and room when communicating over telecommunication to ensure correct patient is being discussed. All units had staff educated and signed off between September 2024- October 2024. Sign-offs were sent to PGC, and audits began in November 2024.

Results: From November 2024 to March 2025 over 447 audits were completed over 40 units. Identification using room numbers was shown to be inefficient for the emergency department. This was due to patients switching locations related to incoming patient needs. It was found the patient’s full name and date of birth was more efficient within their unit. Of the 447 audits 92% used Call, Check, Connect to identify patients over the phone.

Implication for nursing practice: By ensuring correct patient verification, the goal is to decrease patient safety events related to identification. This is a nurse driven quality improvement created at our site.

Document Type

Poster

Publication Date

11-12-2025


 

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Nov 12th, 12:00 AM

Patient Identification: Call Check Connect

Background: Lack of staff participation in verifying correct patient in conversations via phone or in-person has led to an increase in patient safety events within our site.

Local problem: While receiving telemetry monitoring, a patient experienced sustained bradycardia (slow heart rate). When the concern was initially escalated to the care team, there was confusion regarding which patient was experiencing the clinical decline. The lack of use of the high reliability tool read/repeat back and patient identifiers lead to a delay in escalation to the clinician and a clinical intervention delay. Ultimately leading to a major safety event.

Method: The safety event was brought to the Professional Governance Council (PGC). The PGC created the initiative “Call, Check, Connect”. Using this patient identifier the goal is to verify patient first/last name and room when communicating over telecommunication to ensure correct patient is being discussed. All units had staff educated and signed off between September 2024- October 2024. Sign-offs were sent to PGC, and audits began in November 2024.

Results: From November 2024 to March 2025 over 447 audits were completed over 40 units. Identification using room numbers was shown to be inefficient for the emergency department. This was due to patients switching locations related to incoming patient needs. It was found the patient’s full name and date of birth was more efficient within their unit. Of the 447 audits 92% used Call, Check, Connect to identify patients over the phone.

Implication for nursing practice: By ensuring correct patient verification, the goal is to decrease patient safety events related to identification. This is a nurse driven quality improvement created at our site.

 

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