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Honouring patient's resuscitation wishes: a multiphased effort to improve identification and documentation
  1. Nicola Schiebel1,
  2. Sarah Henrickson Parker2,
  3. Richard R Bessette3,
  4. Eric J Cleveland4,
  5. J Paul Neeley5,
  6. Karen T Warfield6,
  7. Mellissa M Barth6,
  8. Kim A Gaines6,
  9. James M Naessens7
  1. 1Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2National Center for Human Factors Engineering in Healthcare, MedStar Health, Washington, DC, USA
  3. 3Division of Systems and Procedures, Mayo Clinic, Rochester, Minnesota, USA
  4. 4School of Graduate Medical Education, Mayo Clinic, Rochester, Minnesota, USA
  5. 5Design and Research, Neeley Worldwide, London, UK
  6. 6Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
  7. 7Division of Health Care Policy & Research, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Nicola Schiebel, Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, USA, 55905;schiebel.nicola{at}


Background Do Not Resuscitate (DNR) orders are intended to safeguard patients' autonomy and prevent unwanted resuscitative care. However, DNR orders may be miscommunicated between health care providers, leading to errors honoring patient wishes during cardiac arrest events. This project focused on improving accuracy of DNR ordering processes for an academic, tertiary care hospital.

Intervention We describe a performance improvement process and outcomes for implementation of an inpatient electronic ordering system that included an automated, decentralized printing process for resuscitation status armbands. Specific phases of this project involved: (a) identification of common factors contributing to errors honoring patients‘ resuscitation wishes, (b) design of an electronic ordering process, (c) design and integration of a new DNR armband and (d) evaluation of the impact of changes on communication accuracy. The primary outcome was percentage of patients with incorrect designation of resuscitation status on armbands compared to the active resuscitation order in the electronic medical record.

Results After implementation of an electronic ordering process we identified that 37/196 (19%) patients had an armband that did not reflect their documented wishes versus 2/103 (2%) after integration of automated armband printing into the process (p<0.001). No armband discrepancies were found after the first two weeks of post-implementation audits.

Conclusions Design and implementation of an electronic ordering and armband labeling process reduced discrepancies between patient wishes and the armband labeling of the patient's desired DNR status. It is anticipated that these improvements will reduce the risk of adverse outcomes, and better align clinical processes with patient wishes.

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