Overview
Correctly identifying patients and matching patients to their intended treatment is fundamental to safe care. Patient identification is such a routine process in the complex healthcare system, and it can be perceived as unimportant. Yet, the risk of wrong-patient errors is real and ever-present.
A few salient points on patient identification:
- Patient identification mistakes can happen in every healthcare setting, from hospitals, medical centers, and nursing homes to pharmacies and clinics.
- Incorrect patient identification can occur at any stage throughout the patient’s encounter in the care continuum, during registration, receiving treatment to post-treatment.
- Many wrong-patient mistakes are discovered before care is provided. However, some errors reach patients and lead to patient harm, with grave consequences.
- Patient misidentification can be a root cause of other problems and clinical incidents with catastrophic adverse effects, such as wrong-site surgery.
- No one is immune from making a wrong-patient error and no system is infallible.
- Most, if not all, wrong-patient errors are preventable.
The Joint Commission has made patient identification the No.1 IPSG (International Patient Safety Goal) since 2003 when the first set of patient safety goals was published. The National Quality Forum has listed patient identification errors as serious reportable events and a high-priority area for measuring health information safety. Many public health agencies have also made patient identification one of their national patient safety goals, including MOH Malaysia.
Despite efforts to advocate for safe practices to ensure correct patient identification, errors continue to occur. A report by the Joint Commission published in 2018 identified 409 sentinel events of patient identification out of 3,326 incidents (12.3%) between 2014 and 2017.
Table of Contents
Patient Identification During Care Process
Patient identification is the process of correctly matching patients to their intended care and communicating information about the patient’s identity accurately and reliably throughout the continuum of care.
The care process can be broadly divided into three phases to analyze patient identification events:
Phase 1: Admission or registration
Phase 2: Delivery of care, treatment, and diagnostics, including transfer and discharge
Phase 3: Post-treatment; example – referrals, consultation, electronic prescribing.
Physical identification of the patient occurs throughout the three phases. At least two patient identifiers approved by the organization should be used. Approved patient identifiers can include:
- Patient’s full name and date of birth
- Unique identifiers such as patient identification or medical record number
- Bar-coded wristbands containing patient identification information
- Biometric identification
- Patient photograph
Technologies with features that facilitate patient identification, such as bar-code scanners, computerized provider order entry (CPOE) system, and Electronic Health Records (EHR) play an important in preventing identification mistakes. However, improper use of these technologies or errors in data entry can contribute to wrong patient events.
Analysis of Wrong-patient Events
A study published by ECRI Institute in 2016 on over 7,500 wrong-patient events occurring between January 2013 and August 2015 provided some insightful statistics:
- Most of the failures (72.3%) occurred during patient encounters (Phase 2), and another 12.6% occurred during admission and registration (Phase 1). Very few failures were identified during the post-encounter phase (Phase 3).
- Of the failures that occurred during patient encounters, 36.5% involved diagnostic procedures (diagnostic imaging, laboratory medicine, pathology), and 22.1% involved treatments (medications, procedures, and transfusion).
- Wrong-patient events involving the physical identification of patients accounted for about 15% of all the failures identified; most of these events fell into three categories; wristband missing, patient identity not verified, or wristband identifiers incorrect.
- About 15% of events were associated with technology contributing to patient identification errors.
Strategies to Prevent Wrong-Patient Errors
To effectively address wrong-patient errors, it is recommended that healthcare providers take a system approach and implement an organization-wide patient identification system. Following the Plan-Do-Check-Act methodology, the system should entail the following key strategies:
- Developing clear and comprehensive policies, procedures, and protocols that apply across the organization to:
- Standardize the approach to patient identification among different facilities within a healthcare system. For example, the use of a white ID band on which specific information (name and date of birth, patient ID) could be written.
- Emphasize the primary responsibility of healthcare workers to check the identity of patients and match the correct patients with the intended care before the care is administered.
- Use at least two identifiers to verify a patient’s identity upon admission, prior to the administration of care, and during the processes of transferring responsibility for care.
- Provide clear protocols for identifying patients who are impaired or lack identification.
- Keep records on identification and matching processes that have occurred.
- Implementing patient identification processes:
- During admission or registration.
- When matching a patient’s identity to care, treatment, or services.
- Whenever responsibility for care is transferred – handover, transfer, and discharge.
- In specific service settings if they are different from those generally used across the organization.
- Ensure patient identification techniques and protocols are consistently applied for every patient encounter.
- Monitoring and evaluating patient identification system:
- Establish mechanisms for monitoring the effectiveness of the patient identification system and identifying opportunities for improvement.
- Review of compliance with relevant policies, protocols, and procedures.
- Reporting and reviewing patient identification mismatching events and near misses is a critical component of an organization-wide patient identification system.
- Taking actions for continuous improvement:
- Information from evaluation, audit, and monitoring processes should reported to the executive and used to identify actions for improvement.
- Investigation and RCA on wrong-patient incidents should lead to appropriate actions being taken to mitigate risk.
- Review of policies and procedures and develop new protocols.
- Provide comprehensive training and education to all staff members involved in patient care on the use of the identification system.
- Educate and engage patients and their families on the importance of correct patient identification. Encourage patients and their families to be active participants in the process, to express concerns about safety and potential errors, and to ask questions about the correctness of their care.
Safe Patient Identification Practices: Do’s and Don’ts
| DO’S | DON’TS |
|---|---|
| Confirm two approved patient identifiers at the beginning of every patient encounter. | Use a room or bed number to identify a patient. |
| Apply patient identification techniques consistently. | Assume every patient will correct you when you use the wrong patient name. |
| Ask the patient to state his/her name and the other identifiers by asking “What is your name? What is your date of birth?” | Ask the patient to confirm his/her name by asking, “Is your name XYZ?” |
| Take measures to avoid mix-ups when patients have similar names. | Place patients with similar names in the same room. |
| Clearly display the patient’s name and other identifiers on wristbands, forms, etc. | Deviate from the organization’s patient identification policies. |
| Actively engage patients during the patient identification process. | Carry multiple pre-printed specimen labels for different patients. |
| Minimize interruptions and distractions during the patient identification process. | Remain silent when you observe deviations from patient identification policy. |
| Exchange patient-specific identifiers during patient hand-offs. | Assume another caregiver involved in a patient’s care has already positively identified a patient. |
| Label specimen containers with two patient identifiers in the presence of the patient. | Ignore patients when they ask questions on the need to conduct patient identification. |
In Closing
Patient identification is fundamental to safe care. The risk of wrong-patient events is real and ever-present in all healthcare settings. Healthcare organizations can mitigate wrong-patient risk by adopting a system approach. Develop clear policies and protocols on patient identification; ensure the procedures are consistently followed; review compliance and take actions for continuous improvements.
You can ensure care is delivered to the right patient every time by confirming two patient identifiers at the beginning of every patient encounter and always follow the organization’s patient identification policies. Patient safety is your priority.
Reporting patient identification events and near misses is a critical component of the patient identification system, a topic we will discuss in our next blog.
Patient Identification is one of the incident types under the Clinical Incidents category in QUASR Incident Reporting System. Contact us to learn more about how QUASR facilitates the reporting of wrong-patient incidents and near misses, investigation, RCA, and improvement actions.
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