Introduction to Patient Identification

Patient Identification: A Review of Current Literature and Advancements.

By: Unknown

Week 4 Paper

MISG730 -

Submitted: December 9, 2007

Introduction to Patient Identification

Today's dynamic health-care environment provides us with many additional challenges and obstacles in accurately identifying patients (Beyea 2003). The process of identifying patients isn't a fool-proof process simply because humans are not perfect and we have yet to develop a system that can help us avoid simple lapses in judgment. Many facilities have attempted to implement several setting-specific solutions; however a wide-scale implementation of an error-proof system does not exist. Proper patient identification has become such an important issue that even accreditation organizations like JCAHO have included it in their patient safety initiatives (Schraag, 2006). Obviously the nature of a medical facility, geography and the wide variety of health-care delivery systems make it difficult for clinicians to routinely spend time verifying each patient's identity. The following discussion explains the purpose of patient identification systems and some of the steps hospitals are taking to combat identification errors.

Purpose of Patient Identification and Common Problems

The international heath-care community suffers from an on-going problem of mistaken patient identity (Joint Commission International Center for Patient Safety, 2007). Failing to properly identify a patient can result in unnecessary procedures, inappropriate tests, incorrect prescriptions, or even discharging the wrong patient. There are two primary reason a health-care facility should properly identifying a patient: (1) To correctly identify a particular individual as an actual patient of the facility (2) To correctly associate a patient with a reason(s) of admission (Di Lima , Johns, & Liebler, 1998). In a study of patient safety at US Veteran Hospitals (Mannos, 2003), nearly 100 patient misidentifications were reported in a period, between January 2000 to March 2003. In the UK there have been nearly 236 incidents of misidentification reported to the National Patient Safety Agency in a two-year period between 2003 and 2005 (National Patient Safety Agency, 2005). Fortunately clinicians, administrators, and public advocacy groups have made significant progress in developing methods and guidelines to reduce patient identification errors (Joint Commission International Center for Patient Safety, 2007).

There are four important purposes and objectives that are accomplished when a hospital and the respective clinician correctly identifies a patient (Di Lima et al., 1998). The first objective is the ability to distinguish between individuals who might share a first or last name (Di Lima et al., 1998). In an FDA study of transfusion errors from 1976 to 1985, 10 patient deaths were the result of patients sharing the same last name (Schraag, 2006). The second objective is to allow a facility to link documents, records, charts and other vital patient information to that unique patient (Di Lima et al., 1998). In a study conducted by the Journal of the American Medical Association missing information from patient records were correlated with a higher probability for medical errors (Smith, Araya-Guerra, Bublitz, Parnes, Dickinson, Van Vorst et al. 2005).

The third objective is to provide clinicians with the means to retrieve relevant clinical data that may be stored either physically or electronically (Di Lima et al., 1998). In the US, nearly 195,000 people die each year as a result of preventable medical mistakes thus the importance of mistaken patient identity is serious a serious matter (Healthgrades, 2004). Finally a good patient identification system serves as a source of statistical information for factors such as survival rate or success rate (Di Lima et al., 1998). The ever increasing use of electronic communication systems provides facilities with a greater number of opportunities to improve access and distribution of patient information (Fitterer, Mettler, & Rohner , 2007). One of the simplest ways to ensure the right care is being delivered to the correct patient is to regularly verify the identity of the patient at the point-of-care (Beyea, 2002).

There are two major approaches health-care organizations can take to minimize the damage from poorly identifying patients. One is a social approach that seeks to improve communication between patients and other clinicians (Joint Commission International Center for Patient Safety, 2007). That means getting more individuals, clinicians and patients alike, more aware of the problem and to place more emphasis on active communication. One well-known study cites that problems with patient identification are often not the result of a single error or the mistake of a single person, but rather the result of a combination of factors (Chasin & Becker, 2002). The study chronicles the events surrounding a 67-year-old woman who was admitted for a cerebral angiography, but mistakenly underwent an invasive cardiac electrophysiology study. The authors identified nearly 17 distinct errors made by the staff that ultimately resulted in the patient undergoing unnecessary procedures. Communication between both patients and clinicians is an important aspect of ensuring the right individuals are receiving the proper treatments (Schraag, 2006). The second approach is through technological means by the way of improved patient tracking, wrist-bands, color-coded charts, radio-frequency identification, or various other electronic or physical identifiers (Joint Commission International Center for Patient Safety, 2007). It should be noted that regardless of the amount of technology we use it is still humans that provide end-services, thus the possibility of human error will always remain (National Patient Safety Agency, 2004).

Communication Barriers

Major errors in patient identification are the result of poor communication between staff members and their patients (Beyea, 2002). Clinicians often make the mistake of relying on their past encounters with patients as means of identifying patients. Instead of taking a few moments to correctly identify a patient through some very simple clinical cues many clinicians set up a dangerous paradigm that puts their patients in harms ways. Finding ways to reduce communication barriers is a fundamental and critical step in providing dependable patient care and preventing mistakes. A good first step is to simply raise awareness among clinicians that such a problem