Healthcare News & Insights

Prevent patient identification errors

Sometimes, hospital staff confuse two patients for one another, or pull the wrong chart for a patient due to similar sounding names or illnesses. These patient identification errors can cause serious harm, and they’re more common in hospitals than they should be. 

doctor-and-nurse-with-patientA new report from patient safety organization ECRI Institute discusses the issue of misidentifying patients in hospitals.

According to the report, ECRI analyzed errors and near-misses submitted by healthcare organizations to determine the extent to which issues involving identification occurred in facilities.

The organization looked at thousands of events involving patient identification. Most (72%) took place during patient encounters, and over half of them dealt with either diagnostic procedures (36.5%) or treatment (22%). Documentation problems accounted for an additional 10%.

Per ECRI’s analysis, almost all events that could’ve caused serious harm to the patient were caught before anything terrible took place. However, there were two submitted events relating to patient identification that led to patient deaths. In both cases, documentation errors played a role in the outcome.

Some facilities rely on technology to reduce these errors, including electronic health records (EHR) systems with alerts to flag providers for any issues and bar-code scanners to confirm patients’ identities.

But these methods aren’t foolproof. ECRI found that technology played a role in 15% of patient misidentification errors.

Keys to reduce mistakes

Because “wrong patient” errors can have serious consequences, it’s important to regularly train hospital staff on the appropriate identification protocol for patients. That can nip these problems in the bud before they happen.

According to the report, here are some general best practices to pass along to doctors, nurses, and other providers and staff members:

  • Use two patient identifiers to confirm the person’s identity at the beginning of each encounter. Patient identifiers can include the patient’s name, date of birth, unique hospital ID number, Social Security number or photo. Staff shouldn’t use bed locations, room numbers or diagnoses to identify patients.
  • Avoid “leading” the patient when asking for identifiers. An open-ended statement like “Please tell me your name.” is better than asking “Are you Mrs. Jones?” Reason: Patients are often disoriented when they’re in the hospital, so they may not be listening to staff closely and can accidentally confirm an incorrect name or other identifier.
  • Have protocols in place for patients in the same unit or department with similar names. Identification errors can happen easily when patients’ names sound similar. Be sure to have alternate identifiers available for patients in this case, and avoid putting patients with similar names in the same room.
  • Confirm patients’ identity before labeling specimen containers. Staff shouldn’t label containers until the specimen’s been collected. After double-checking identification information for the patient, attach the label to the container in the patient’s presence. It’s best to only carry multiple preprinted specimen labels for one patient at a time so the wrong one won’t get used.
  • Note any patient-specific identifiers during handoff conversations. Shift changes are one of the most common times when mistakes of all kinds happen in hospitals. This can often be attributed to incomplete handoff conversations. Make sure staff are relaying information about the identifiers used for each patient, and have them confirm the patient’s identity upon the start of their shift.
  • Engage patients in the identification process. Before getting basic demographic information from each patient, ask if there are any accommodations they need to better communicate these details to providers (e.g., translators), and find resources to meet those needs. In addition, let them know about the importance of getting the right data to avoid identification errors.

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  1. I have questions, not sure who can answer them but here they are.
    When this happens, what is legal recourse for the patient harmed?
    If they ever find out that is, disclosure is key, and do hospitals tell is my question?
    Lastly how would a victim, the harmed patient prove he was a medical error, followed by adverse event, due to a never event that has been concealed from patient and family. ? Would it be strict liability? Or malpractice? Who will review patient records to confirm, yes or no victim of duplicate, overlays, etc. And what would the cost be to do so? Please advise…thank you.

  2. Joshua Imuzeghe says:

    One of the ways we can prevent patient/clients identification errors in our various hospital is by asking the patient/client their second name. E.g. EDWARD David Imafidon the second name will help to identify the patient/client’s name and to take proper documentation on the procedures, treatment and diagnosis.