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Study: Patient Identification Errors can Prove Fatal

September 27, 2016
by Heather Landi
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While most patient identification errors are caught before patients are harmed, some wrong-patient events are fatal and many have the potential to cause harm, yet, the majority of these misidentifications are preventable and technology can play a critical role, according to the findings of an ECRI Institute report.

ECRI Institute Patient Safety Organization (PSO), a patient safety research group, studied more than 7,600 wrong-patient events during a 32-week period as part of its Deep Dive report on patient identification and the risk of wrong-patient errors.

According to the study, the majority of patient identification failures (72 percent) occurred during patient encounters and 12 percent occurred during the intake process, which includes registration and scheduling, such as admitting a patient under another patient’s medical record or creating duplicate records at registration.

Of the more than 7,600 wrong-patient events analyzed, 91 percent were caught before they caused any harm to patients, yet about 8 percent (143 events) contributed to or resulted in temporary harm to the patient and required intervention. Three events resulted in temporary harm and required initial or prolonged hospitalization and one error led to permanent patient harm. Additionally, two errors required intervention to sustain the patients’ lives.

Two wrong-patient events associated with patient deaths involved documentation failures. In one fatal error, the wrong patient record was accessed, and in the other event, the wrong patient’s documentation was used to give another patient clearance for surgery, the study authors wrote.

In addition to their potential to cause patient harm, patient identification errors are particularly troubling, according to the study authors, because many of these mismatches affect at least two people. “For example, when a patient receives a medication intended for another patient, both patients—the one who received the wrong medication and the one whose medication was omitted—can be harmed,” the study authors wrote.

Additionally, more than half of the patient identification failures involved either diagnostic procedures or treatment. Diagnostic procedures cover laboratory medicine, pathology and diagnostic imaging and accounted for 36 percent of wrong-patient events. Treatment, which accounted for 22 percent of wrong-patient events, covers medications, procedures and transfusions.

Ten percent of the patient identification failures occurred during the documentation phase.

Wrong-patient events involving physical identification of patients constituted about 15 percent of all the failures identified; most of these events fell into three categories—wristband missing, patient identity not verified or wristband identifiers incorrect.

The study authors also found that technology contributes to patient identification errors as well with 15 percent of events (1,148 events) associated with technology. Examples of technology-associated errors include entering orders in the wrong patient’s chart or administering a patient’s medications before confirming the patient’s identity with bar-code scanning. Additionally, the study authors highlighted an event in which clinicians retained previously recorded patient demographic data when a new patient is connected to physiologic monitoring equipment, or matching portable telemetry equipment with the wrong patient.

Underlying all phases of the patient care process is physical identification of the patient using at least two patient identifiers as well as various technologies with features that facilitate patient identification, the study authors wrote. “These technologies include electronic health records (EHRs), computerize provider order entry (CPOE) systems, bar-code scanners, physiologic monitors, electronic prescribing capability, and more. While the inappropriate use of these technologies can contribute to wrong-patient errors, when used properly these systems also play a role in preventing identification mistakes.”

“These events occur during multiple procedures and processes and can involve nearly anyone on the patient’s healthcare team. As a result, no single strategy can prevent these events; instead, organizations must adopt a multipronged approach to prevent wrong-patient mistakes,” the report authors wrote.

Several ECRI Institute PSO members and collaborating organizations shared their stories about identification errors and the steps they took to improve patient identification. “Their experience makes clear that wrong-patient errors can be prevented, starting with an organizational commitment to improve,” the study authors wrote.

The report authors recommend patient identification strategies involving policies, procedures, registration, standardization, technology, patient and family engagement and event reporting and response.

Among the key recommendations, strong leadership is critical, the report authors wrote, staring with communicating to staff the expectation that patient identification is essential for safe care and is an organizational priority.

Healthcare leaders also are encouraged to examine their organization’s work processes—for example, conduct a failure mode and effects analysis—to uncover any latent system-wide problems with patient identification. “The Deep Dive analysis found that lapses in adhering to an organization’s patient identification policy were a contributing factor for events that led to patient harm,” the study authors wrote.

With regard to the role of technology, the report recommends organizations adopt measures to prevent patient mismatches that occur when patient information is incorrectly recorded in bedside equipment, such as point-of-care tests and physiologic monitors.

The ECRI Institute also recommends organizations look at technology such as bar coding or radio frequency identification to support patient identification.

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