Patient Identification Errors
Preventing patient identification errors has been an area of significant research and work for many years. While much progress has been made, there is still work to be done. Patient identification errors can occur in every healthcare setting, during multiple processes, and are often preventable . This article serves to review some landmark publications relating to patient identification errors over the last 15 years and summarize where this important focus is heading.
Defining patient identification and errors thereof can vary based on the focus and goals of the organization. Here are a few definitions of patient identification.
Joint Commission – Using acceptable person-specific identifiers, such as the patient’s name, an assigned identification number, or telephone number, patient identification is the process to reliably identify the individual as the person for whom the service or treatment is intended and to match service or treatment to that individual .
ECRI Institute – Patient identification is the process of correctly matching a patient to appropriately intended interventions and communicating information about the patient’s identity accurately and reliably throughout the continuum of care .
Office of the National Coordinator for Health Information Technology (ONC) – Accurate patient identification ensures that the information presented by and entered into the Electronic Health Record (EHR) is associated with the correct person .
Many organizations are involved with improving patient identification. While not inclusive, this list contains many of the leading and well-known organizations.
Joint Commission (JC) – a United States-based, non-profit, tax-exempt organization that accredits healthcare organizations and programs. Most states recognize Joint Commission accreditation as a condition of licensure and for the receipt of Medicaid and Medicare reimbursements .
National Academy of Medicine (formerly the Institute of Medicine) – a non-profit, non-governmental organization that provides unbiased, evidenced-based, authoritative information and national advice on issues relating to medicine and health .
National Quality Forum (NQF) – a non-profit, membership organization representing consumers, health plans, medical professionals, employers, government/public health agencies, and pharmaceutical/medical device companies in the development of consensus-based standards to promote patient protection and healthcare quality .
World Health Organization (WHO) – a specialized agency of the United Nations that acts as the leading, directing, and coordinating authority on international health matters critical to public health .
Office of the National Coordinator for Health Information Technology (ONC) – a staff division of the Office of the Secretary, within the US Department of Health and Human Services, which leads national health information technology (IT) efforts and is charged as the principal federal entity to coordinate nationwide efforts to implement and use the most advanced health IT and the electronic exchange of health information .
ECRI Institute – an independent, non-profit, international organization that partners with more than 5,000 healthcare organizations to share knowledge, experience, and research on topics such as patient safety improvement, comparative effectiveness, Risk Management, quality management, evidence-based practice, and healthcare processes .
There have been many important publications and studies over the past 15 years, which are highlighted below.
- 2003 - The Joint Commission publishes the first set of National Patient Safety Goals to help accredited organizations address specific areas of concern in regard to patient safety. The first goal was to improve the accuracy of patient identification. Recommended actions included using two patient identifiers when collecting blood or administering medications and conduct a time-out prior to the start of any surgical or invasive procedure in order to confirm the patient, procedure, and site.
- 2004 - The Institute of Medicine (now the National Academy of Medicine) publishes the second installment in its patient safety series, titled Patient Safety: Achieving a New Standard of Care, following the first report, To Err is Human: Building a Safer Health System, in 1999. Amongst many findings, this report found that adverse events and near misses share a common pathway. The report advocates for a new health system that prevents errors from occurring and learns from them when they do occur .
- 2004 - The Joint Commission publishes the Universal Protocol standard as an extension and continuation of their National Patient Safety Goals to prevent wrong-site, wrong-procedure, wrong-patient surgery.
- 2007 – The World Health Organization’s Collaborating Centre for Patient Safety Solutions unveils nine solutions to prevent healthcare errors that harm millions of people throughout the world. One solution focused on correct patient identification. It was noted that failures to correctly identify patients is widespread and recommendations placed emphasis on methods for verifying patient identity .
- 2008 - Ross Koppel, PhD et al. publishes an article titled Identifying and Quantifying Medication Errors: Evaluation of Rapidly Discontinued Medication Orders Submitted to a Computerized Physician Order Entry System which found that medication orders discontinued within two hours had a high likelihood of predicting patient identification errors .
- 2011 - The institute of Medicine (now the National Academy of Medicine) publishes the third installment in its patient safety series, titled Health IT and Patient Safety: Building Safer Systems for Better Care, which warns that health IT can cause patient harm .
- 2013 - Jason Adelman, MD MS et al. publish an article titled Understanding and Preventing Wrong-Patient Electronic Orders in which they describe a retract-and-reorder tools, building on the findings of the publications above. The tool captures occurrences in which a provider places an order on a patient, cancels the order, and then places the same order on another patient within 10 minutes. The tool has a positive predictive value (PPV) of 76% and found that 1 in 37 patients within the study institution had a incident of patient identification error .
- 2014 – The Office of the National Coordinator for Health Information Technology (ONC), in conjunction with Dean Sitting, PhD; Joan Ash, PhD, MLS, MBA; and Hardeep Singh, MD, MPH release the Safety Assurance Factors for EHR Resilience Guides (ONC Issues Guides for SAFER EHRs). These guides are designed to help healthcare organizations conduct self-assessments to optimize the safety and safe use of EHRs in nine distinct areas, one being patient identification .
- 2015 - The National Quality Forum approves measure 2723, Wrong-Patient Retract-and-Reorder (WP-RAR) Measure, based off the work of Jason Adelman et al. described above .
- 2016 - The National Quality Forum lists patient identification as a key measurement area in their finalized report on the Identification and Prioritization of Health IT Patient Safety Measures .
- 2016 - ECRI Institute publishes the Top 10 Patient Safety Concerns for Healthcare Organizations, which includes patient identification errors, finding them frequent, serious, and having broad implications .
- 2016 - ECRI Institute publishes the fifth installment of their Deep Dive analyses into patient safety, titled Patient Identification Executive Summary .
In summary, patient identification errors can occur in any healthcare setting and during multiple processes. ECRI Institute identifies three key phases of care during which patient identification errors may occur. The first, is intake, which includes registration and scheduling. The second is the encounter, which includes diagnostic testing, treatment, monitoring, documentation, discharge, transport, and handoffs. The final phase is post-encounter, which includes Health Information Exchange, electronic prescribing, referrals/consults, and patient portals . More than 70% of patient identification errors analyzed by ECRI Institute from January 2013 to August 2015 occured during the encounter phase.
ECRI Institute and others give specific recommendations for improvement in seven distinct areas .
- communicate expectation and priority of preventing patient identification errors
- identify strengths and weaknesses in regards to patient identification
- provide resources and support initiatives relating to patient identification
Policies and Procedures
- uncover latent system-wide problems contributing to patient identification errors
- standardize verification protocols for patient identification
- train staff by sharing and discussion patient identification errors
Patient and Families
- engage patients and families in patient identification
- encourage patients and families to speak up and ask questions
- actively use patient portals
- use biometric methods to improve patient identification
- foster a supportive work environment amongst those engaged in patient identification
- implement a quality assurance (QA) plan with specific metrics in regards to patient identification
Standardize and Simplify
- improve usability and readability of patient identification bands
- ensure consistency of The Joint Commission Universal Protocol
- develop a list of invasive procedures outside of the operating room that require Universal Protocol
- ensure safety and safe use of health IT
- use health IT to actively improve patient identification
- embed patient photographs within the EHR and other systems
Event Reporting and Response
- foster a culture of reporting patient identification errors
- analyze patient identification errors in a structured format
- conduct proactive risk assessments of patient identification errors
Finally, the following are examples of how technology and informatics can be used to reduce patient identification errors in the future.
- using vein scans (like PalmSecure) or other biometric data to confirm patient identification
- scanning a patient’s barcoded identification band could trigger the creation of a context-specific note or record, including an embedded photograph 
- radio frequency identification (RFID) in Healthcare settings could be used to open the correct patient’s chart when a listed team member approaches the patient
- patient identification verification or reentry could be used when medication orders are placed 
- additional automatic monitoring, measures, or global trigger tools, like the retract-and-reorder tool, could be used to capture patient identification errors in real-time
- ECRI Institute. Patient Identification: Executive Summary. August 2016. https://www.ecri.org/Pages/Patient-Identification-Deep-Dive.aspx
- The Joint Commission. National Patient Safety Goals Effective January 1, 2015. 2015. http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdf
- The Office of the National Coordinator for Health Information Technology. Safety Assurance Factors for EHR Resilience Guides. January 2014. https://www.healthit.gov/safer/
- About The Joint Commission. Accessed October 18, 2016. https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx
- About the National Academy of Medicine. Accessed October 18, 2016. https://nam.edu/about-the-nam/
- About the National Quality Forum. Accessed October 18, 2016. http://www.qualityforum.org/About_NQF/
- About the World Health Organization. Accessed October 18, 2016. http://www.who.int/about/en/
- About the Office for the National Coordinator of Health Information Technology. Accessed October 18, 2016. https://www.healthit.gov/newsroom/about-onc
- About ECRI Institute. Accessed October 18, 2016. https://www.ecri.org/about/Pages/default.aspx
- The Institute of Medicine. Patient Safety: A New Standard for Care. The National Academies Press. 2004. https://www.nap.edu/catalog/10863/patient-safety-achieving-a-new-standard-for-care
- The World Health Organization Collaborating Centre for Patient Safety Solutions. Nine Patient Safety Solutions. 2007. http://www.who.int/patientsafety/events/07/02_05_2007/en/
- Koppel, R et al. Identifying and Quantifying Medication Errors: Evaluation of Rapidly Discontinued Medication Orders Submitted to a Computerized Physician Order Entry System. Journal of the American Medical Informatics Association 2008: 15, 461-465.
- The Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. The National Academies Press. 2011. https://www.nap.edu/catalog/13269/health-it-and-patient-safety-building-safer-systems-for-better
- Adelman, J et al. Understanding and Preventing Wrong-Patient Electronic Orders. Journal of the American Medical Informatics Association 2013: 20, 305-510.
- National Quality Forum. Wrong-Patient Retract-and-Reorder (WP-RAR) Measure. Measure 2723. 2015. http://www.qualityforum.org/QPS/2723
- National Quality Forum. Identification and Prioritization of Health IT Patient Safety Measures. 2016.
- ECRI Institute. Top 10 Patient Safety Concerns for Healthcare Organizations. April 2016. https://www.ecri.org/Pages/Top-10-Patient-Safety-Concerns.aspx
Submitted by Kyle Marshall