Study: Risk of patient identification errors 'ever present'

Failing to associate the right patient with the appropriate action, referred to as wrong-patient errors, is a prevalent occurrence with potentially fatal consequences, according to a report from the ECRI Institute, a nonprofit research group that studies patient safety.

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The ECRI report examined 7,613 wrong-patient events occurring from January 2013 to July 2015 that were submitted by 181 healthcare organizations. The events were voluntarily submitted and may represent only a small portion of all wrong-patient events occurring at the organizations, ECRI officials said.

Of the 7,613 wrong-patient events studied, about 9 percent led to temporary or permanent harm or even death.

"Although many healthcare workers doubt they will actually make a mistake in identifying their patients, ECRI Institute PSO [Patient Safety Organization] and our partner PSOs have collected thousands of reports that show this isn't the case," William M. Marella, ECRI Institute executive director of PSO operations and analytics, said in a statement. "We've seen that anyone on the patient's healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists and transporters."

The report found that the majority of wrong-patient events (72.3 percent) took place during patient encounters, while another 12.6 percent occurred during the intake process.

Also, researchers said, more than half of wrong-patient events involved either diagnostic procedures (2,824 or 36.5 percent) or treatment (1,710 or 22.1 percent). Diagnostic procedures cover laboratory medicine, pathology and diagnostic imaging. Treatment covers medications, procedures, and transfusions.

Additionally, the report found the majority of the events for which a harm score was provided, using National Coordinating Council for Medication Error Reporting and Prevention, were caught before they caused any harm (1,601 of 1,752 events, or 91.4 percent).

And the two wrong-patient events associated with patient deaths involved documentation failures; in one event, the wrong patient record was accessed, and in the other event, the wrong patient's documentation was used to give another patient clearance for surgery, researchers said.

"ECRI Institute PSO's Deep Dive analysis of wrong-patient events shows that the risk of errors is ever present for the multitude of patient encounters occurring daily in healthcare settings," they concluded. "These events occur during multiple procedures and processes and can involve nearly anyone on the patient's healthcare team. As a result, no single strategy can prevent these events; instead, organizations must adopt a multipronged approach to prevent wrong-patient mistakes."

The researchers recommended leaders of healthcare organizations communicate to staff the expectation that patient identification is essential for safe care and is an organizational priority; ask questions about the organization's patient identification practices and experiences to identify strengths and opportunities for improvement; and provide support for the organization's patient identification improvement initiatives.


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