Preventable, Potentially Fatal Patient Identification Errors Analyzed by ECRI Institute Patient Safety Organization (PSO)

PLYMOUTH MEETING, PA—In its newest analysis of patient safety errors, ECRI Institute PSO today releases a Deep Dive review of reported events involving patient identification. The risk of failing to associate the right patient with an action, referred to as wrong-patient errors, is significant and may be driven by increasing patient volume, frequent handoffs among providers, and increasing interoperability and data sharing among IT systems.

A key take-away from ECRI Institute's research is that most, if not all, wrong-patient errors are preventable.

Most patient identification mistakes are caught before care is provided, but the events in this report illustrate that others do reach the patient, sometimes with potentially fatal consequences. About 9% of the events led to temporary or permanent harm or even death.

"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," says William M. Marella, MBA, MMI, ECRI Institute executive director of PSO Operations and Analytics. "We've seen that anyone on the patient's healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists, and transporters."

Analysis of the reported events illustrate that:

• Incorrect patient identification can occur during multiple procedures and processes, including but not limited to patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and emergency care.
• Patient identification mistakes can occur in every healthcare setting, from hospitals and nursing homes to physician offices and pharmacies.
• No one on the patient's healthcare team is immune from making a wrong-patient error.
• Many patient identification errors affect at least two people. For example, when a patient receives a medication intended for another patient, both patients—the one who received the wrong medication and the one whose medication was omitted—can be harmed.

ECRI Institute PSO reviewed more than 7,600 wrong-patient events occurring over a 32-month period that were submitted by 181 healthcare organizations. The events are voluntarily submitted and may represent only a small percentage of all wrong-patient events occurring at the organizations.

Given that correct patient identification is fundamental to safe care, the Joint Commission has made accurate patient identification one of its National Patient Safety Goals since 2003 when the first set of goals went into effect. The Joint Commission is not alone in advocating for safe practices to ensure correct patient identification. The National Quality Forum lists wrong-patient mistakes as serious reportable events and also considers patient identification as a high-priority area for measuring health information technology (IT) safety.

Mainstream media has also called attention to the issue. Despite the attention given to correct patient identification, mistakes continue to occur. ECRI Institute PSO's new report highlights solutions that have worked for other healthcare organizations.

The ECRI Institute PSO Deep Dive: Patient Identification executive summary is available for free download at www.ecri.org/patientid. The full report and companion evidence review are available to all ECRI Institute PSO and partner PSO members and for purchase by non-members. Hospitals can also participate in a confidential INsight™ Assessment on patient identification to help them assess opportunities to reduce errors and improve patient safety.  Additional research will be shared with the public by the Partnership for Health IT Patient Safety in early 2017.

For questions about this topic, or for information about purchasing the report, please contact ECRI Institute PSO by telephone at (610) 825-6000, ext. 5558; by e-mail at pso@ecri.org; or by mail at 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA.