Even though the patients shared the same first name, the mixup should have been avoided. Nevertheless, one patient was wheeled into the operating room for cataract surgery and came out implanted with a lens intended for the other.
The incident, recounted in a new report on patient identification by ECRI Institute Patient Safety Organization, is not exactly an outlier, unsettling as that prospect may be to patients. Identification errors happen all the time, in all manner of healthcare settings, ECRI's report showed. And although the problem is well recognized, fixing it has been slow going.
“The problems that we're seeing with patient identification are ubiquitous,” said Bill Marella, ECRI Institute's executive director of PSO Operations and Analytics. “This happens every day in any healthcare organization of any size,” he added. Those working in the industry are well aware of the problem, but it has mostly flown under the radar of the general public.
In the report, released Sunday, researchers analyzed 7,613 patient safety events including near misses involving inaccurate patient identification, from 181 healthcare organizations. It scrutinized these events and classified them to figure out what went wrong and what consequences, if any, ensued.
Anyone terrified that they're fated to suffer irreparable damage as a result of mistaken identity the next time they set foot in a hospital need not panic. When the researchers analyzed 1,752 patient identification cases for which harm scores were reported, in 1,601 of them, or 91.4%, patients were ultimately not harmed.
When patients were hurt, the damage was temporary in 146 instances. In one case, a patient was permanently harmed, and in two others, the error required an “intervention” to keep the patient alive. Twice, error “may have contributed to or resulted in” death, the report found.
In 2003, the Joint Commission designated accurate patient identification as a National Patient Safety Goal. The World Health Organization has also recognized misidentification as a threat that can result in “medication errors, transfusion errors, testing errors, wrong person procedures, and the discharge of infants to the wrong families.”
Although the problem is difficult to quantify, growing limitations on working hours for clinicians translates to more handoffs for patients, which in turn raises the likelihood of communication problems and other opportunities for misidentification, the WHO has said.
The fact that ECRI's analysis could be done at all is groundbreaking, said Dr. Jason Adelman, the chief patient safety officer and associate chief quality officer at Columbia University Medical Center/New York-Presbyterian Hospital, who collaborated on and contributed to the report.
Only in the last decade has openly discussing and studying patient identification errors become possible, thanks to the 2005 Patient Safety and Quality Improvement Act. The law created a voluntary reporting system and Patient Safety Organizations -- ECRI Institute PSO is one of them -- where healthcare providers could confidentially report medical errors, without fear of punishment.
By collecting this information in a standardized fashion, “we can break it down and really understand wrong patient errors,” Adelman said.
72.3% of identification errors happened during clinical encounters, such as when patients are being seen by doctors, or undergoing operations or testing, the ECRI report found. A minority -- 12.6% -- of errors happened during intake, when patients are being registered or scheduled for care. Very few errors followed the clinical care phase.
During clinical encounters, 36.5% of mistakes took place during diagnostic procedures and 22.1% during treatment.
In an ideal world, healthcare would happen in a highly reliable system where no one is hurt and everyone gets the care they need. In reality, “we're all human,” said Adelman, and, of course, to err is human. A doctor could be in the middle of admitting one patient when she is interrupted by a call requesting medication for another. When she returns to the first patient, she forgets to switch back to his record.
“The solution is to make systems so strong that human errors don't reach patients,” Adelman said.
Electronic health records often contain features to strengthen patient identification, but healthcare organizations don't always maximize these systems' full potential.
Most EHR vendors allow providers to upload a patient photo that providers can use to check the identity of the patient before them. Yet only about 20% of hospitals use that feature, said Marella. “That's some low-hanging fruit,” he added.
In other situations, revising practices and protocols that have long gone unquestioned could also diminish the possibility of identifying patients inaccurately. Some hospitals still use a system of referring to patients by their room number, for instance, but what if a patient switches rooms?
Because the most effective ways of preventing patient identification problems vary by institution, it's up to healthcare leaders to be proactive in addressing the problem and identifying systemic flaws and gaps unique to their institutions, Marella said.
CEOs should be asking their staff what the hospital is doing to ensure that electronic health records use high-quality data, to standardize the patient identification process, and to identify the biggest barriers to following those protocols, he added. If healthcare leaders are proactive, they can make positive changes that “bake safety into the system.”