How to Avoid Wrong-Patient Errors

by Kurt Ullman •

“If you have leaders pushing away reports, being smug, and not creating the right culture, problems follow,” said Dr. Shah. “With any size of practice, you need to talk about safety and quality. It doesn’t have to be formal, and don’t overthink it. Something as easy as a safety huddle a couple of times a week goes a long way toward shaping the culture.”

Key components of a successful event reporting system include:

  • A supportive environment that protects the privacy of the staff reporting occurrences;
  • Reporting mechanisms that are easily accessed by the entire team, not just physicians and nurses;
  • Summaries of reports and actions taken that are disseminated in a timely fashion so the staff knows their reports are important and are taken seriously; and
  • Mechanisms in place to ensure that the responsibility for reviewing reports and developing action plans is clearly outlined.

“Medicine is very much a team sport, and there is a growing awareness that inter- and multidisciplinary teams are critical in achieving favorable outcomes for the patient,” said Dr. Brenner. “Start with the first person who touches the patient, either literally or virtually, including the front desk, nursing and medical assistants, and any other ancillary service. We are absolutely all in this together.”

Ask for Assistance

Physicians and their staffs shouldn’t be intimidated by an imposing and confusing set of concerns. “Practices don’t realize that they can lean on the performance and quality improvement departments of the hospitals they have affiliations with,” said Dr. Shah. “These departments can help with materials, literature searches, and plan-do-study-act cycles. They can leverage both these resources and those available from [their] malpractice insurance provider.”

Finding and addressing WPEs are part of the do-no-harm promise physicians make to their patients every day. “If you are not a constant student of safety and quality and you are not a student of your results as a physician, then you are not going to get better,” said Dr. Brenner. “If there was nothing to be done, we’d counsel patients that these things happen, but it wouldn’t change lives much. The fact that we know that by doing some simple things we prevent these ‘wrong’ things puts the onus squarely on us to find and act on them.”

Kurt Ullman is a freelance medical writer based in Indiana.

ECRI Recommendations for Proper Patient Identification

  • Use a standardized protocol to evaluate problems in your patient identification processes.
  • Ensure that staff members involved in identifying patients receive the necessary training and understand the importance of adhering to established procedures.
  • Enable patients to view and access information about hospitalizations and physician visits through a secure patient portal.
  • Ensure that technology is used safely and correctly to prevent patient mismatches.
  • Develop clear ways to evaluate, implement, and monitor the use of new technologies to improve patient safety.
  • Incorporate usability improvement strategies to minimize risk of human error in health IT systems.
  • Conduct audits to monitor compliance trends.

Tips For Avoiding Patient Misidentification

  1. Use more than one patient identifier in records and interactions when possible. In addition to name, consider date of birth, home address, and/or social security number.
  2. Develop protocols for staff assessment of patient identification, such as checking the ID band and getting the patient to tell his or her full name. Make sure these protocols are used.
  3. Ask open-ended questions. Many patients may answer “yes” when asked if they are Mr. Smith, even when they aren’t. This is especially likely in the pre-operative setting or with patients who are hard of hearing.
  4. Refer to each patient by name and not by room number or diagnosis.
  5. If possible, use multiple identifiers when accessing electronic medical records to make sure you have pulled up the correct information and not the record of a person with a similar name.
  6. Don’t have more than one record open at a time. If you get distracted, results or orders may end up in the wrong patient’s file.

For More Information

The Value of Precise Patient Identification. The Healthcare Financial Management Association released this educational report geared toward the physician’s office. It offers an outline for understanding the metrics, the risks of poor patient identification, and strategies for more accurate patient identification. It is available at hfma.org.