By CS Copeland, PhD
“Do-the-2. Verify two patient identifiers — every patient, every time."
This pithy advice from the University of Texas Medical Branch at Galveston is no silly call for extra typing. Medical errors have been considered as the third leading cause of death in the United States, and prominent among these are errors stemming from mistaken patient identification, arguably one of the easiest types of medical errors to prevent.
The most well-known and feared patient identification errors are surgical errors —wrong site, wrong procedure or wrong patient surgeries. Although rare, dramatic cases are often widely reported in popular media and spread rapidly through social networks: removal of a healthy kidney instead of a diseased one, removal of a breast when no cancer was present and the widely reported recent case of a brain surgery conducted on the wrong patient.
Much more common are the sorts of day-to-day errors that result in less severe morbidity or near misses, such as medication not being given to a patient who needs it because it was instead given to another patient with the same name. (Cases such as this affect not just one but two patients: the one who needed the medication but did not receive it, and the one who was given unneeded—and possibly harmful—medication.) Such errors, stemming from patient or sample misidentification, have led to diagnoses and test results attributed to the wrong patient, medication being given to the wrong patient and discharge of infants to the wrong families. Mistakes resulting from patient identification errors include:
incorrect patient registration
incorrect patient data entry
incorrect entry of orders
collection of biological specimens from the wrong patient
inappropriate labeling of samples
erroneous transmission of test results down the laboratory information chain
missing clinical information (if it was entered into another patient’s chart)
Of particular concern are identification errors involving infants, who cannot speak about their identities. The risk of misidentification is also heightened because many newborns do not yet have official names when they are born. The traditional convention of giving them hospital names based on the last name of the mother, gender of the baby and a sequential medical record number can result in identical or highly similar designations, with medical record numbers that are also highly similar to other newborns born the same day. (For example, it would not be a great surprise for two Baby Boy Smiths to be born on the same day, in which case, their medical record numbers might only differ by the last digit.)
Patient Identification Accuracy as a National Patient Safety Goal
Since 2014, the Joint Commission, a non-profit that certifies and accredits US healthcare organizations, has named improving the accuracy of patient identification as the first of its National Patient Safety Goals. The main goal of improving the accuracy of patient identification is broken into two sub-goals: using at least two patient identifiers when providing care, treatment and services, and eliminating transfusion errors related to patient misidentification.
Use at Least Two Patient Identifiers When Providing Care, Treatment and Services
Wrong-patient errors can occur at virtually any stage of diagnosis and treatment, and can be prevented through the simple practice of using at least two patient identifiers for all patients. This practice works both by (1) reliably identifying which patient needs the service or treatment and (2) matching the service or treatment to that individual. Identifiers can be the patient’s name, an assigned identification number, a telephone number or another person-specific identifier. A patient’s room number or physical location is not considered an acceptable identifier. In particular, at least two patient identifiers should be used when:
Administering medications, blood or blood components
Collecting blood samples, biopsies or other specimens for clinical testing
Providing treatments or conducting procedures
In addition to identifying containers used for blood and other specimens with at least two patient identifiers, the labeling should be done in the presence of the patient, and not at a later time.
As mentioned above, newborn patients present a heightened risk for misidentification. To prevent this, a distinct naming system should be used, and this system should include use of the mother’s first as well as last name along with the baby’s gender for identification. For identification banding, two body sites should be used. Barcoding can also be used for identification. In addition, staff should be directed to communicate clearly when newborns have similar names, such as by using signage to alert colleagues; for example, “Baby Boy Judy Smith, not to be confused with Baby Boy Joan Smith.”
Eliminate Transfusion Errors Related to Patient Misidentification
Transfusion represents an area of particular concern because of its high risk for morbidity — for example, a simple misidentification can easily lead to a patient receiving blood of the wrong type. Preparation of blood products is generally conducted with high diligence to safety, so most errors (about 70%) occur at the point of transfusion into the patient. Elimination of transfusion-related patient identification errors is therefore given special consideration by the Joint Commission as its own sub-goal.
Before initiating a blood transfusion or blood component transfusion, the Joint Commission recommends that (1) the blood or blood component must be matched to the order; (2) the patient must be matched to the blood or blood component; and (3) either a two-person verification process or a one-person verification process accompanied by automated identification technology, such as bar coding, must be used. When using a two-person verification process, one of the two individuals must be the qualified transfusionist who will administer the blood or blood component to the patient and the other must be qualified to participate in the process, as determined by the hospital.
The Importance of a Thoughtfully Designed Program
As with other National Patient Safety Goals, such as reducing the number of hospital-associated infections and reducing the harm associated with clinical alarm systems, a thoughtfully designed program is key to success. Well-designed programs engage all relevant employees in a healthcare-team effort, with commitment from all members to best practices. To do this, the program should include education not just on the new procedures, but also on why they are important. Knowing the rationale behind new policies — in this case, how much harm patient identification errors can cause and how easily they can be prevented — can go far in building commitment from all team members, a fundamental element for achievement of any patient safety goal.
Dr. CS Copeland holds a BA in neuropsychology from the University of California at San Diego and a PhD in molecular and cellular biology from Tulane University, specializing in parasitology and virology, with postdoctoral research in molecular entomology and computational genomics.