Professional Documents
Culture Documents
Patient Identification: Statement of Problem and Impact
Patient Identification: Statement of Problem and Impact
Patient Identification
The major areas where patient misidentification can occur a. Emphasize the primary responsibility of health-care
include drug administration, phlebotomy, blood transfusions, workers to check the identity of patients and match
and surgical interventions. The trend towards limiting working the correct patients with the correct care (e.g. labora-
hours for clinical team members leads to an increased number tory results, specimens, procedures) before that care
of team members caring for each patient, thereby increasing is administered.
the likelihood of hand-over and other communication prob- b. Encourage the use of at least two identifiers (e.g. name
lems (3). Because patient misidentification is identified as a and date of birth) to verify a patients identity upon ad-
root cause of many errors, the Joint Commission, in the United mission or transfer to another hospital or other care set-
States of America, listed improving patient identification accu- ting and prior to the administration of care. Neither of
racy as the first of its National Patient Safety Goals introduced these identifiers should be the patients room number.
in 2003, and this continues to be an accreditation requirement
c. Standardize the approaches to patient identification
(4). While in some countries wristbands are traditionally used among different facilities within a health-care system.
for identifying hospitalized patients, missing bands or incor- For example, use of white ID bands on which a stand-
rect information limit the efficacy of this system. Colour cod- ardized pattern or marker and specific information (e.g.
ing of wristbands facilitates rapid visual recognition of specific name and date of birth) could be written, or
issues, but the lack of a standardized coding system has lead implementation of biometric technologies.
to errors by staff who provide care at multiple facilities (5).
d. Provide clear protocols for identifying patients who medication and prior to any diagnostic or therapeutic
lack identification and for distinguishing the iden- interventions.
tity of patients with the same name. Non-verbal
Encourage patients and their families or surrogates to be
approaches for identifying comatose or confused
active participants in identification, to express concerns
patients should be developed and used.
about safety and potential errors, and to ask questions
e. Encourage patients to participate in all stages of the about the correctness of their care.
process.
f. Encourage the labeling of containers used for blood Potential Barriers:
and other specimens in the presence of the patient. Difficulty in achieving individual behaviour change to
comply with recommendations, including the use of
g. Provide clear protocols for maintaining patient sam-
short cuts and workarounds.
ple identities throughout pre-analytical, analytical,
and post-analytical processes. Process variation among organizations within a geo-
graphic area.
h. Provide clear protocols for questioning laboratory
results or other test findings when they are not con- Process variation where there may be regional facilities
sistent with the patients clinical history. staffed by the same practitioners (for example, colour-
i. Provide for repeated checking and review in order coded wrist bands with different meanings in different
to prevent automated multiplication of a computer organizations).
entry error. Costs associated with potential technical solutions.
2. Incorporate training on procedures for checking/ Integration of technology within and across
verifying a patients identity into the orientation and organizations.
continuing professional development for health-care
Perception by health-care providers that relationship
workers.
with the patient is compromised by repeated verification
3. Educate patients on the importance and relevance of of patient identity.
correct patient identification in a positive fashion that
Technological solutions that fail to consider the reality of
also respects concerns for privacy.
clinical care settings.
Looking Forward: Increase in staff workload and time spent away from
patient care.
Consider implementation of automated systems (e.g.
electronic order entry, bar coding, radiofrequency Typing and entry errors when registering patients on
identification, biometrics) to decrease the potential for computerized systems.
identification errors, where feasible. Cultural issues, including:
Stigma associated with wearing an identification
Strength of Evidence: band.
Expert consensus and reports of significant error reduc-
tion from individual facilities after implementing revised High risk of patient misidentification due to name
patient identification processes. structure, close similarity of names, and inaccura-
cies in birth dates for elderly patients.
Applicability: Patients using health cards belonging to other indi-
In all health-care settings. viduals, in order to access services.
Clothing that conceals identity.
Opportunities for Patient and Lack of familiarity with local names for increasing
Family Involvement: number of foreign health-care workers.
Educate patients about the risks related to patient
Insufficient generally accepted research, data, and
misidentification.
economic rationale regarding cost-benefit analy-
Ask patients or their family members to verify identifying sis or return on investment (ROI) for implementing
information to confirm that it is correct. these recommendations.
Ask patients to identify themselves before receiving any
Risks for Unintended
Consequences:
Not assessing the basic processes for care while be- Elimination of human checking processes when auto-
coming preoccupied with technical and non-technical mated systems are implemented.
devices or solutions.
Rapid replication of errors in linked computer systems
Reliance on technical solutions without adapting the masking patient identification errors.
workflow process related to the new support systems.
Possible compromising of patient confidentiality and
Reliance on imperfect technical solutions as if they
privacy by standardized identification systems.
were perfect.
EXAMPLE OF
Patient Identification
Emphasize that health-care providers have primary responsibility for checking/verifying a
Policy patients identity, while patients should be actively involved and should receive education on
the importance of correct patient identification.
Upon admission and prior to the administration of care, use at least two identifiers to verify a
Admission patients identity, neither of which should be the patients room number.
Even if they are familiar to the health-care provider, check the details of a patients
Intervention identification to ensure the right patient receives the right care.