Avoiding Patient Identification Errors

Patient identification errors can result in increased medical costs, delays in treatment or diagnosis, and in some cases, serious injury or death. In fact, patient identification errors are such a serious and persistent issue that The Joint Commission has identified “improving the accuracy in patient identification” as one of the National Patient Safety Goals every year since their inception in 2002. Consequences of patient misidentification are exemplified in the following case.

Case Summary: 

Mary, an 84-year-old with dementia, was a long-term care patient in a nursing home. The patient’s medication administration record (MAR) on the morning of the incident indicated the night LPN, an agency nurse, had administered Mary’s usual 6 a.m. medications–two tablets–just before shift change.
 
At 7 a.m., Mary’s roommate, Maria, told the day nurse that although she typically received a cup “full of pills” every morning at 6 a.m., she had only been given two pills that morning. Maria’s MAR, however, indicated she had received all her usual meds. 
 
Upon learning of Maria’s concern, the day nurse approached the night LPN, who had not yet left, and asked if she had given Maria all her morning medicines. The LPN replied that she had given Maria a “full cup” of pills and Mary her usual “two pills.”
 
Approximately 90 minutes later, Mary became lethargic, hypoxic, hypotensive, and bradycardic. Concerned that the night nurse may have given Mary the medications intended for Maria, the day nurse called for EMS assistance, informing them of the probable medication error. Mary remained hospitalized for several weeks but never fully recovered. She was discharged to a skilled nursing facility, where she died a month later. The lawsuit filed by Mary’s family alleged that the medication error had resulted in injuries that led to her death.

Correct patient identification is crucial to ensuring safe, quality medical care. Proper identification helps prevent such errors as administering the wrong treatment or medication, performing procedures on the wrong patient, or accessing the wrong medical records. Across the care continuum, accurate patient identification helps healthcare practitioners maintain continuity of care and effective communication within a healthcare team, thereby preserving patient trust and improving the patient experience. 
 
Preventing patient identification errors protects your organization against:

• Professional liability claims.
• Regulatory challenges.
• Reputational damage.
• Revenue loss. 

One study estimates the average hospital loses $17.4 million dollars per year in denied insurance claims due to patient identification error. 

Risk Management Recommendations

The best way to protect patients and your organization from the harm of patient misidentification is by implementing standardized procedures and fostering employee vigilance. Consider the following strategies when reviewing your organization’s patient identification policies and procedures: 

• Analyze your data. Conduct a thorough analysis of the patient identification errors and near misses that occur in your organization to detect trends or patterns. Use that data to identify systems or processes that are contributing to error and target interventions accordingly.
• Standardize procedures. Implement a standardized patient identification process across the healthcare system to ensure consistency and accuracy. Patient identification data should contain the same information/attributes and appear in the same format regardless of where it is being displayed [e.g., wristband, headers, and electronic medical record (EMR) displays]. Align patient identification practices with patient privacy and security regulations to protect sensitive medical information.
• Use two patient identifiers. Engage the patient in identifying themselves and require the use of at least two patient identifiers prior to providing any care or services. Clearly outline the process to identify noncommunicative patients/residents (e.g., newborn, comatose, or confused patients). Establish a two-person verification process for critical procedures and treatments, where two healthcare practitioners independently verify patient identity before proceeding. When feasible, include information that enhances identification, such as a photo. 
• Discourage pre-labelling of specimens. Ensure that policies and procedures are in place to verify correct labelling of patient specimens at the time they are collected. Specimen containers should never be pre-labelled. Include the patient in the verification process whenever possible by having them verify their name and date of birth prior to placing the label on the specimen container. 
• Optimize available technology. Understand and leverage electronic health record capabilities and advanced technologies, such as biometric identification, barcode scanning, and radio-frequency identification to maintain accurate patient information and facilitate proper identification. Consider implementing automated systems to decrease human error where feasible. Design your EMR to provide alerts to facilitate proper identification, such as an alert to identify similar or misspelled names. 
• Educate staff. Provide ongoing training to all healthcare staff, including temporary staff, on the importance of patient identification, the correct identification process, and the potential risks associated with errors. Emphasize the important responsibility of each healthcare worker to identify the correct patient for each procedure, treatment, or service. Caution healthcare workers to avoid assumptions. Never assume a patient’s identity. Even if you recognize them, verify their identity using established identifiers.
• Enlist patients. Patients can be powerful allies in preventing identification errors. Educate patients about the importance of verifying their identification and personal information. Encourage them to actively participate in all stages of the identification process and give them opportunities to verify their personal information.
• Monitor compliance. Conduct routine audits of patient identification practices to identify any gaps or deviations from established protocols. Use audit findings to drive continuous improvement.

Patient identification errors can result in adverse events, professional liability claims, and revenue loss. Proactive risk mitigation strategies, including standardized processes, technology optimization, and staff education, can prevent these errors and improve the quality of care in your organization. 

Additional Resources:

• Office of the National Coordinator for Health Information Technology. Safety Assurance Factors for EHR resilience (SAFER).