Patient ID errors happen—and they can be deadly

To err is human, as they say. But in a hospital setting, an error can turn deadly fast. And they do, according to a report from the Emergency Care Research Institute (ECRI), especially when hospital records confuse two patients for one another.

The report shows that between January 2013 and August 2015, there were 7,613 wrongly identified patient events in 181 hospitals (which voluntarily shared the info). In some cases, clinicians, family members or patients realized the mix-ups before there was an issue. But in other cases, patients died in situations that could have been prevented with a better organized identification process, according to the report.

For example, one patient was not resuscitated after a heart attack because he was confused with a patient who had a do-not-resuscitate order on file. Another person was given the wrong eye lens implants for cataract surgery when the patient’s file was confused with another person’s with the same first name. The report included mentions of other particularly egregious errors resulting from patient identification mistakes: incorrect medication dosing, patients who wrongly underwent imaging procedures or were mistakenly anesthetized, and babies on maternity wards who were fed the wrong mothers’ milk—and then had to be treated for the hepatitis B found in that milk.

Most of the issues happened during a physician-patient encounter, especially in diagnostic and treatment settings, though about 13 percent occurred during patient intake.

Out of 1,752 patient identification errors evaluated for harm, only two resulted in patient death. But 149 of the errors required some kind of intervention to correct the error and might have resulted permanent damage to the patient. The vast majority either did not cause significant harm to the patient and only require monitoring or did not fully reach the patient at all.

These confusions range from inconvenient to devastating. The good news is that they’re preventable, according to the report.

The potential for mix-ups within the patient identification process is plentiful, according to the report, and might seem small at the time they happen. Maybe there was a misspelling during intake, or a clinician marked an order for one patient on another patient’s charts or a record was transferred to a new provider incorrectly. There were also issues when physicians didn’t start each visit or exam with asking the patient to identify themselves with their full name or didn’t ask for a two-point personal identifier. Sometimes physicians or other hospital officials mistakenly relied on personal identification information given by a cognitively impaired patient.

The ECRI report authors offered recommendations to healthcare providers in regards to leadership, procedural and technological improvements to reduce the risk of such errors, plus a quick-glance dos and don'ts list.

Hospitals should emphasize the importance of following existing patient identification strategies for patient safety and implement a standardized practice for identifying patients at different stages in their hospital stay or treatment course, the authors recommended. Hospitals can also use biometrics info during intake, such as a vein pattern scan, and simplify the design of patient I.D. bracelets, which could include barcodes or other electronically integrated identification methods. Administrators should foster a culture of openness when it comes to reporting patient I.D. errors and near-misses, the report advises, so adjustments can be made where necessary.

ECRI ended with a directive to physicians: “Even if you think you know your patient, use the two patient identifiers. Patient safety is your priority.”