Despite adoption of the Joint Commission's "dual identifier" mandate, the number of near-miss wrong-patient events in diagnostic imaging remains significant, according to the results of a study published in the August 2015 issue of the American Journal of Roentgenology. The study, which evaluated the imaging reports of 1,717,713 examinations performed at two hospitals in a large academic health system between January 1, 2009, and May 30, 2013, found that 67 near-miss wrong-patient events occurred—an estimated rate of 4 per 100,000 imaging examinations. The researchers categorized 35 (52%) of these events as mislabeling-misidentification events and 32 (48%) as wrong dictation events. The data indicated that the most common reported modality for mislabeling-misidentification events and dictation events was radiography (86% and 59%, respectively), with most involving portable chest radiography (69% and 44%, respectively). The researchers conclude that efforts should be made to improve systems learning and the timely reporting of events in diagnostic imaging. To decrease the frequency of these events, they recommend implementing best practices and adopting technology solutions, such as a radiology information system that opens the dictation platform and matches a patient's images simultaneously, decreasing the frequency of wrong dictation errors. Other strategies to decrease the rate of wrong-patient errors suggested by the researchers include developing a policy for the radiology department that outlines a process for the technologists to follow when examinations are mistakenly performed on the wrong patient or wrong body part, conducting a monthly audit of wrong-patient errors that involves a review of electronic protocol critiques and feedback to the technologists, and implementing a facial photo–based patient identification technique.

HRC Recommends: Numerous potential causes for patient identification errors have been cited. Common causes include defective policies and procedures, failure to follow appropriate policies and procedures, same or similar patient names, incorrect information recorded on patient name stamps or wristbands, duplicate medical record numbers, communication failure, and lack of automated processes. Choosing patient identification as an area in which to perform a proactive risk assessment, such as a failure mode and effects analysis, may result in the uncovering of latent systemwide problems as well as problems that are specific to particular departments, such as diagnostic imaging.