- Providers regularly misidentify patients for procedures or other actions, sometimes with deadly consequences, a new analysis by the ECRI Institute shows.
- The risk of medical record mix-ups is “significant,” spurred by increasing patient volume, frequent handoffs among providers, and issues with interoperability and data sharing among different IT systems, the group says.
- Despite those challenges, most, if not all, patient errors are preventable.
ECRI’s Patient Safety Organization reviewed 7,613 wrong-patient events voluntarily reported by 181 healthcare organizations between January 2013 and July 2015. As such, they may represent just the tip of the iceberg of all medical record mix-ups.
“Although many healthcare workers doubt they will actually make a mistake in identifying their patients, ECRI Institute PSO and our partner PSOs have collected thousands of reports that show this isn’t the case,” William Marella, executive directive of PSO operations and analytics at ECRI, said in a statement. “We’ve seen that anyone on the patient’s healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists, and transporters.”
Patients can be incorrectly identified at just about any point in their healthcare journey — from registration and electronic data entry and transfer to medical and surgical procedures, testing, drug treatment, blood transfusions and patient monitoring. And the error often affects at least two people — e.g., if one patient gets the wrong medication, the patient for whom it was intended may not receive what he or she was prescribed.
To cut down on such occurrences, the adoption of standardized protocol to verify patient identifies was recommended, The Wall Street Journal reports. They should also standardize how names are displayed in electronic medical records and attach patient photos. Patients and families can help to reverse the trend by actively questioning diagnostic tests and treatments.
Common practices like the bar code on a patient’s wristband with that on a medication order could also be expanded to include blood test, X-rays, and other actions, the report says.
Under federal law, providers can share safety data, including medical errors, without fear of liability. Medical errors account for 251,000 deaths every year, researchers at Johns Hopkins School of Medicine reported this year.
Both the Joint Commission and the National Quality Forum consider accurate patient identification a top priority, and NQF lists ID mix-ups as a serious reportable event.