The success of many treatments and activities within healthcare facilities depends on ensuring that correct patient identity has been established. Patient identification is an essential stage in care processes as there could be significant consequences if an error is made. Failure to correctly identify patients continues to result in medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families.
The major areas where patient misidentification can occur include drug administration, phlebotomy, blood transfusions, and surgical interventions.
Strategies
The following strategies should be considered :
- Ensure that healthcare organizations have systems in place that:
- Emphasize the primary responsibility of health-care workers to check the identity of patients and match the correct patients with the correct care (e.g. laboratory results, specimens, procedures) before that care
- is administered.
- Encourage the use of at least two identifiers (e.g. name and date of birth) to verify a patient’s identity upon admission or transfer to another hospital or other care setting and prior to the administration of care. Neither of these identifiers should be the patient’s room number.
- Standardize the approaches to patient identification among different facilities within a health-care system. For example, use of white ID bands on which a standardized pattern or marker and specific information (e.g. name and date of birth) could be written.
- Provide clear protocols for identifying patients who lack identification and for distinguishing the identity of patients with the same name. Non-verbal approaches for identifying comatose or confused patients should be developed and used.
- Encourage patients to participate in all stages of the process.
- Encourage the labeling of containers used for blood and other specimens in the presence of the patient.
- Provide clear protocols for maintaining patient sample identities throughout pre-analytical, analytical, and post-analytical processes.
- Provide clear protocols for questioning laboratory results or other test findings when they are not consistent with the patient’s clinical history.
- Provide for repeated checking and review in order to prevent automated multiplication of a computer entry error.
- Incorporate training on procedures for checking/verifying a patient’s identity into the orientation and continuing professional development for health-care workers.
- Educate patients on the importance and relevance of correct patient identification in a positive fashion that also respects concerns for privacy.
Patient and family involvement
- Educate patients about the risks related to patient misidentification.
- Ask patients or their family members to verify identifying information to confirm that it is correct.
- Ask patients to identify themselves before receiving any medication and prior to any diagnostic or therapeutic interventions.
- Encourage patients and their families or surrogates to be active participants in the identification, to express concerns about safety and potential errors, and to ask questions about the correctness of their care.
Barriers
- Difficulty in achieving individual behavior change to comply with recommendations, including the use of short cuts and workarounds.
- Process variation among organizations within a geographic area.
- Process variation where there may be regional facilities staffed by the same practitioners (for example, color coded wrist bands with different meanings in different organizations).
- Costs associated with potential technical solutions.
- Integration of technology within and across organizations.
- Perception by health-care providers that relationship with the patient is compromised by repeated verification of patient identity.
- Technological solutions that fail to consider the reality of clinical care settings.
- Increase in staff workload and time spent away from patient care.
- Typing and entry errors when registering patients on computerized systems.
- Cultural issues, including:
- Stigma associated with wearing an identification band.
- High risk of patient misidentification due to name structure, close similarity of names, and inaccuracies in birth dates for elderly patients.
- Patients using health cards belonging to other individuals, in order to access services.
- Clothing that conceals identity.
- Lack of familiarity with local names for an increasing number of foreign healthcare workers
References:
- Wristbands for hospital inpatients improves safety. National Patient Safety Agency, Safer practice notice 11, 22 November 2005. http://www.npsa.nhs.uk/site/media/documents/1440_Safer_Patient_Identification_SPN.pdf
- Mannos D. NCPS patient misidentification study: a summary of root cause analyses. VA NCPS Topics in Patient Safety. Washington, DC, United States Department of Veterans Affairs, June–July 2003
- Patient Safety Solutions, volume 1, solution 2 ,May 2007. WHO http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf
- (http://www.va.gov/ncps/TIPS/Docs/TIPS_Jul03.doc, accessed 11 June 2006).
- Thomas P, Evans C. An identity crisis? Aspects of patient misidentification. Clinical Risk, 2004, 10:18–22.
- 2006 National Patient Safety Goals. Oakbrook Terrace, IL; Joint Commission, 2006 (http://www.jcipatientsafety.org/show.asp?durki=10293&site=164&return=10289, accessed 11June 2006).
- Use of color-coded patient wristbands creates unnecessary risk. Patient Safety Advisory Supplement, Vol. 2, Sup. 2. Harrisburg, Pennsylvania Patient Safety Authority, 14 December 2005 (http://www.psa.state.pa.us/psa/lib/psa/advisories/v2_s2_sup__advisory_dec_14_2005.pdf, accessed 11 June 2006).
- Edozien L. Correct patient, correct site, correct procedure. Safer Health Care, 27 July 2005. http://www.saferhealthcare.org.uk/NR/rdonlyres/6D89DBA8
- Right patient—right care. Improving patient safety through better manual and technology-based systems for identification and matching of patients and their care. London, National Patient Safety Agency, 2004 (http://www.npsa.nhs.uk/site/media/documents/781_Right%20patient%20right%20care%20
- final%20report.pdf, accessed 11 June 2006).
- Dighe A et al. Massachusetts General Hospital—bar coded patient wristband initiative: a CPM initiative.
- IHI National Forum storyboard presentation, December 2004; Safety Improvement Reports. saferhealthcare, 2005
- Wright AA et al. Bar coding for patient safety. New England Journal of Medicine, 2005,354:329–331.
- Emerging technology: hospitals turn to RFID. HealthLeaders, August 2005 http://www.healthleadersmedia.com/print.cfm?content_id=71598&parent=106.
- Secure identification: the smart card revolution in health care. The Silicon Trust, 4 June 2003 (http://www.silicon-trust.com/trends/tr_healthcare.html, accessed 1 April 2007).
Dr. Khalid Abulmajd
Healthcare Quality Consultant