Too often, patient identification errors only receive their due attention after a serious mistake occurs, such as one that results in patient harm. These “sentinel events,” as termed by The Joint Commission, persist despite numerous technological advances and initiatives to focus attention on the issue.
Furthermore, although commonly associated with surgeries, identification errors are not limited to surgical workflows, or to events that cause permanent harm or prompt a life-sustaining intervention; they can occur in any healthcare setting, including inpatient, outpatient, long-term, and ancillary locations. The ECRI Institute notes that more than 7,000 patient identification events, many with serious consequences, were found in its database over a period of about 2.5 years (ECRI Institute, 2016).
Another analysis of more than 1 million medication orders found that 0.064% of those orders were associated with a misidentified patient (Levin, Levin, & Docimo, 2012). While this is a very small percentage, it still means 640 medications were—or could have been—given to the wrong patient. No healthcare organization desires that level of risk, considering the potential consequences to its finances, reputation, and patient trust.
The good news is that patient identification errors are highly preventable with the right identification analyses, workflows, and safeguards in place. Deterrence requires instilling a culture—from the top down—that encourages and rewards proactive assessment of misidentification risk across the continuum of care.
This article, co-authored by OneBeacon Healthcare Group’s Patricia Hughes and published in Patient Safety & Quality Healthcare Magazine, highlights some ways organizations can diagnose the causes and potential causes of patient misidentification, and to prevent such errors to that a safety-focused culture can thrive. Read the full article co-authored by Patricia Hughes, SVP, Risk Management Leader.