More digitization leads to more patient matching errors, adverse events, ECRI finds

Patient identification failures continue to threaten patient safety in hospitals, and the issue partly stems from the growing complexity of healthcare.

The ECRI Institute conducted a deep dive into patient identification. The institute's patient safety organization analyzed 7,613 patient identification events — defined as near-miss events and events that reach the patient and may cause harm — voluntarily submitted by 181 healthcare organizations.

Their analysis found those 7,613 events resulted in 7,740 "failures," or errors associated with patient misidentification, as some of the events had more than one failure.

Examples of wrong-patient events include a patient in cardiac arrest who was not resuscitated because the care team pulled up the wrong patient's record who had a do-not-resuscitate order. A wrong meal tray was given to a patient who was not supposed to receive any food or fluids orally, and the patient choked when trying to eat the food. In another instance, two patients with the same first name were scheduled for cataract surgery, and one patient received the lens intended for the other patient.

"This is a huge problem that the general public isn't aware of," William Marella, executive director for operations and analytics at the ECRI Institute's Patient Safety Organization, told The Wall Street Journal. "Pretty much every clinician involved in your healthcare is at risk of making this kind of error."

The ECRI Institute's analysis found the majority of these failures occurred during patient encounters (72.3 percent) while 12.6 percent occurred during the intake process. More than half the failures involved diagnostic procedures (36.5 percent) or treatment (22.1 percent).

However, most events (91.4 percent) were caught before they caused any patient harm.

Two wrong-patient events were associated with patient deaths, according to ECRI.

The report also indicates 15 percent of events were associated with technology contributing to patient identification errors.

Hardeep Singh, MD, a patient safety researcher at Michael E. DeBakey VA Medical Center and associate professor medicine at Baylor College of Medicine, both in Houston, told WSJ the growing complexity of healthcare is contributing to a rise in patient identification errors.

"We're doing many more lab tests, more imaging tests, more procedures and more transitions through the system," Dr. Singh said. He advised on the report.

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