When a patient walks into a hospital for an appointment, there’s usually an unspoken expectation: They’ll share their name, date of birth and maybe a few other demographic details with a registrar. That helps staff pull the correct medical record, so the patient will be able to see their physician, now armed with their complete medical history and health data.
It seems like a simple process, but the back end is much more complicated, filled with a mix of technological elements like data standards and algorithms, not to mention room for human error.
A few seemingly small, but consequential, problems could emerge if a name or date of birth is entered with a typo, if a patient has recently moved to a new address, if there are inconsistencies in the way addresses are written, or if patients with similar information are confused with one another.
Similar demographics resulted in confusion at a Camden, N.J., hospital in November, after medical staff gave a kidney designated for one patient to another transplant recipient with the same first name, last name and name suffix.
The mix-up took place when a transplant coordinator at the hospital, Virtua Our Lady of Lourdes Hospital, spotted the patient’s name on a transplant list, not realizing there were two patients with the same name. She didn’t review the patient’s date of birth or Social Security number, which would have revealed the mix-up, according to Dr. Reginald Blaber, executive vice president and chief clinical officer at Virtua Health, the hospital’s parent organization.
After a review of the incident, “we realized that we did not have a process in place to safeguard against human error,” Blaber said. “As an institution, we should have had a fail-safe, where we forced her to confirm that she had the right patient—going through multiple means of identification.”
Virtua now uses four identifiers for all transplant patients—name, date of birth, last five digits of the Social Security number and the match number from the United Network for Organ Sharing—and there are multiple points at which a second staff member is required to confirm those details.
“We knew this was not our best day,” Blaber said. “We knew we had to do better.”
The patient who should have received the transplant got a kidney about a week later, according to the hospital.