Patient ID Errors in Healthcare Are Common, but Preventable

Mix-ups in patient identification are a fairly frequent occurrence that can cause real harm to patients. These events are highly preventable with strategies that range from the common sense to the cutting edge, according to a recent study by the ECRI Institute

According to the report by the nonprofit institute’s Patient Safety Organization, “wrong-patient errors can occur at multiple points during a patient’s healthcare encounter and can involve nearly anyone on the patient’s healthcare team.” Identification mistakes can be made in many different medical settings, such as hospitals, pharmacies, physician’s offices, or long-term care centers.

The study, which analyzed 7613 wrong-patient errors occurring from January 2013 through August 2015, grouped each event by failure mode, encounter phase, and harm score. Almost three-fourths (73.2%) of these errors happened during patient encounters, usually diagnostic procedures or treatment.

Although 91.4% of errors were caught before they caused harm to the patient, those that slipped through the cracks caused negative outcomes ranging from inconvenient to disastrous. Among the gravest mistakes described was a situation in which a healthcare team did not attempt to rescue a patient in cardiac arrest because they had incorrectly pulled up the file of a different patient with a do-not-resuscitate order.

Technology was a contributing factor to almost 15% of identification error events, but the report was hopeful that some high-tech solutions could be used to prevent these kinds of mistakes in the future. Suggestions included the use of biometric palm scanning during registration or a radio-frequency identification (RFID) system that automatically pulls up a patient’s file when a nurse wearing an RFID badge walks into that patient’s room.

The study recommends strengthening traditional patient identification methods by ensuring wristbands, records, and labels are correct and consistent. Simple additions like including patient photos in files could potentially allow healthcare providers to immediately notice if they are accessing the information of a patient who is clearly not the patient in front of them.

Improvements in communication between providers and patients can help prevent these mix-ups as well. The report advises asking patients open-ended questions like “What is your name?” as opposed to “Is your name XYZ?” It is also important that patients and their families feel encouraged to speak up if they notice a staff member may have misidentified them.

Finally, changing the mindsets surrounding wrong-patient errors can be just as important as implementing these preventive procedures, according to the report. Healthcare systems should conduct proactive risk assessments, promote adherence to clear protocols, and share examples of previous wrong-patient errors. The goal is to impart a more vigilant mentality among staff members as no one among them is immune to making patient identification errors that can have serious consequences.

Identification errors that cause harm to patients are one of the “never events” that should ideally never occur in a hospital, among others like operations performed on the wrong body part or leaving foreign objects inside the patient after surgery. A previous analysis based on hospital surveys found that 1 in 5 hospitals in the United States lacks a thorough policy in place to address these never events.