Patient identification errors are among the most common patient safety risks, occurring regularly in all settings. Newborns are at particularly high risk of identification errors.
- An identification error can harm two patients rather than just one.
- About 9% of identification errors result in serious harm or death.
- Several strategies can reduce the risk with newborns.
Wrong-patient errors linked to identification are significant and may correlate with increasing patient volume and frequent handoffs among providers, plus increased data sharing, research indicates. Newborns are at particularly high risk of misidentification.
Newborns are at more risk than other patients partly because they cannot participate in their identification, and sometimes even the parents can’t be certain of the baby’s identity just by appearance, says Susan C. Wallace, MPH, CPHRM, patient safety analyst with the Pennsylvania Patient Safety Authority (PPSA) in Harrisburg. She recently authored an article for PPSA on the risks of newborn patient identification. (For more on that report, see related story in this issue.)
“You look at a bunch of babies and they kind of look similar. They’re little, and usually they’re all dressed the same because the hospital likes to use the same pink or blue blankets,” she says. “That creates a challenge for the healthcare worker who is trying to identify one baby from the next.”
The ECRI Institute PSO, a nonprofit research group in Plymouth Meeting, MA, that studies patient safety, reported recently that most patient identification mistakes are caught before care is provided, but others sometimes reach the patient with potentially fatal consequences.
ECRI Institute reviewed more than 7,600 wrong-patient events occurring over a 32-month period that were submitted by 181 healthcare organizations. The events may represent only a small percentage of all wrong-patient events occurring at the organizations, according to ECRI information authored by William M. Marella, MBA, MMI, ECRI Institute executive director of PSO Operations and Analytics.
Anyone Can Make ID Mistake
About 9% of the events led to temporary or permanent harm or even death.
“Although many healthcare workers doubt they will actually make a mistake in identifying their patients, ECRI Institute PSO and our partner PSOs have collected thousands of reports that show this isn’t the case,” Marella says in the information provided by ECRI. “We’ve seen that anyone on the patient’s healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists, and transporters.”
The analysis found that incorrect patient identification occurs most often in patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and emergency care. The report found that 72.3% of the reported errors took place during patient encounters, and another 12.6% occurred during the intake process.
Patient identification errors often affect at least two people, the analysis found. For example, when a patient receives a medication intended for another patient, both patients can be harmed.
Thirty-six percent involved diagnostic procedures and 22% involved treatment. Two wrong patient errors in the study were fatal and both originated with documentation failures. In one case, staff accessed the wrong patient record, and in the other a patient’s documentation was used to give another patient clearance for surgery. (The ECRI report is available online at http://bit.ly/2fgZsD1.)
Misidentification with newborns often results in the baby receiving the wrong breast milk. Though harm does not always occur, there is the worry that a baby may contract a bloodborne disease.
Similar Identifiers Are Common
Wallace notes that newborn misidentification can occur in a variety of circumstances. In one Tennessee case mentioned in her report, she recalls that a pediatrician performed a frenotomy on the wrong newborn because of an identification error. In Virginia, two newborns were switched at birth and discharged to the wrong parents, and a Washington, DC, hospital nurse gave a newborn to the wrong mother, which resulted in the child consuming formula instead of breast milk as intended. (See related story in this issue for more cases of newborn misidentification.)
A 2006 study from Beth Israel Deaconess Medical Center in Boston found an average of 26% of neonatal ICU (NICU) newborns had similar identifiers that put them at risk for misidentification.1
Accurate patient identification has been on The Joint Commission’s list of National Patient Safety Goals since the first set were announced in 2003. The National Quality Forum also lists wrong-patient mistakes as serious reportable events and considers patient identification high priority when measuring health information technology (IT) safety.
TJC recommends using two identifiers for a newborn, and most hospitals use the last name and date of birth. That is not always sufficient, Wallace says.
“Because your son was born with the same birthday as a lot of other babies in the hospital, that’s one of your patient identifiers that is useless in distinguishing that baby from the others,” Wallace explains. “Also, if there is a twin or multiple birth, now they have the same last name and that creates issues.”
Use More Specific Names
The risk is compounded, Wallace notes, by the fact that about 80% of hospitals do not include a first name on the baby’s identification, opting instead to use “Baby Boy” or “Baby Girl” and the mother’s last name.
That problem can be minimized if newborn names can be made more distinctive with a method other than the traditional method of using only the parent’s last name. Incorporating the mother’s first name into the identification can make it more distinctive, Wallace says. “Baby Girl Smith” can be mixed up with another child’s identification far more easily than “Melissa’s Baby Girl Smith.”
Using a unique medical record number as part of the baby’s identification can help, but that also has limitations, Wallace says. They usually are issued sequentially, so the first five or so numbers will be the same for all the babies in the hospital at the same time, making it possible to glance at two record numbers and think they match.
Heel prints also are good practice because they can resolve any confusion between two babies, but they don’t serve as an immediate identification verification, Wallace says.
Technology Can Help
Some hospitals are turning to technology that can help reduce the risk of misidentification. With the increased use of mobile devices such as smartphones and tablets, software developers are starting to create new ID and verification applications designed expressly for clinical use on mobile platforms, says Anton Ansalmar, founder and president of Rapid Healthcare in Irvine, CA.
One such app is used by Pomona (CA) Valley Hospital Medical Center, which has one of California’s largest NICUs with 55 beds and 160 nurses. It is intended to prevent breast milk misfeeds, which can occur even when a hospital has a system for labeling milk bottles, Ansalmar says. The Pomona hospital sought help when the volume of breast milk stored became overwhelming, in part because its existing system did not adequately identify milk left over when a patient was discharged.
“The app works with a login verification on a smartphone and then the NICU nurse uses the phone to scan the baby’s wristband,” Ansalmar says. “The nurse then prints matching labels for the mother’s milk bottles at the bedside. Before feeding, the nurse scans both labels to verify that the right bottle is about to be fed to the right baby.”
The process is integrated into the hospital’s existing electronic medical record. The hospital reported to the app company that more than 70,000 correct verifications were made and more than 480 potential misfeeds prevented in the first year of use.
Reducing the risk requires understanding how and why identification errors occur, Wallace says. In light of her research, she says provider order entry systems physicians can use in the healthcare facility or remotely are helpful.
Labeling errors can be addressed with technology such as bar coding, radio frequency, and bedside label printers, Wallace says. Printing the label at the bedside and placing it on the bottle there minimizes the chance of mislabeling milk or specimens, she says.
Staff and parents also can participate in double-checking labels and patients, she says.
Patient identification bands should be applied to newborns in two sites, such as a wrist and ankle, because their hands and feet are so small that one band may fall off, Wallace notes. Also, parents should be educated on the importance of maintaining them, Wallace says. Encourage patients to report any damaged or smudged identification bands.
Staff also should huddle daily and note any newborns with similar-sounding names or other potential identification risks. The identification bands for those newborns can be marked with a special symbol such as a stop sign or printed reminder that the baby has a name similar to another, such as “Similar name — Confirm identity,” Wallace also suggests these high-risk identification babies can be physically separated as much as possible, such as by placing them on opposite sides of the NICU or a different unit when possible.
“One hospital developed a medication safety policy for babies with the same last name, including twins or triplets, that requires using different color bins,” she says. “The medication for a particular child always goes in that color, which is noted on the patient record and the nurses know to confirm that before proceeding.”
- Gray JE, Suresh G, Ursprung R, et al. Patient misidentification in the neonatal intensive care unit: quantification of risk. Pediatrics 2006 Jan;117(1):437.