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Dangerous Patient Identification Errors and How to Avoid Them

PLYMOUTH MEETING, PA – How often has someone at your hospital done one of the following:

  • Used a room number or bed assignment to identify a patient who has been moved to a different room or bed.
  • Asked a patient to confirm his or her name (“Are you Mr. X?”) instead of asking the patient to state his or her name (“Tell me your name.”).
  • Mistakenly pulled the medical record of a patient with a name similar to that of the intended patient.
  • Entered orders in the wrong patient’s chart.
  • Inquired about the patient’s identity without using two acceptable identifiers or checking the patient’s identification band.
  • Administered a patient’s medications before confirming the patient’s identity with bar code scanning.
  • Relied on patients with impaired ability to confirm their identifying information.

Those errors, as well as some others — admitting a patient under another patient’s medical record, creating duplicate records at registration, retaining previously recorded patient demographic data when a new patient is connected to physiologic monitoring equipment, or matching portable telemetry equipment with the wrong patient — increase the risk that patients will be misidentified, according to a new report from ECRI Institute PSO.

ECRI’s Deep Dive review of reported events involving patient identification emphasizes that wrong-patient errors are significant and often are driven by increasing patient volume, frequent handoffs among providers, and increasing interoperability and data sharing among IT systems.

Yet, the report emphasizes, most, if not all, wrong-patient errors are preventable.

In this review of 7,600 wrong-patient events occurring over a 32-month period that were submitted by 181 healthcare organizations, most patient identification mistakes were caught before care was provided. 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 [patient safety organizations] have collected thousands of reports that show this isn't the case," explained William M. Marella, MBA, MMI, ECRI Institute executive director of PSO Operations and Analytics. "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 ECRI Institutes notes that the events were voluntarily submitted and could represent only a small percentage of all wrong-patient events occurring at the healthcare institutions.

Incorrect patient identification, according to the review, occurs during a range of processes including patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and emergency care, and can happen in every healthcare setting from hospitals and nursing homes to physician offices and pharmacies.

Researchers also found that many patient identification errors affected at least two people: When a patient receives a medication intended for another patient, for example, the harm is done both to the patient receiving the wrong medication and the patient who failed to receive the correct medication.