Skip Navigation LinksHRCAlerts092816_PatientID

​As the healthcare realm becomes more complex, opportunities for patient identification errors are increasing, said a September 25, 2016, article in the Wall Street Journal reporting on the ECRI Institute Patient Safety Organization's (PSO) recently released 2016 Deep Dive. ECRI Institute PSO's report analyzed 7,613 cases of wrong-patient errors at 181 organizations occurring between January 2013 and August 2015. The cases were submitted voluntarily under a federal law that allows providers to share safety data without fear of liability, and probably represent just a fraction of actual identification mix-ups that occurred. Mix-ups reported included a patient in cardiac arrest who was mistakenly not resuscitated because the care team adhered to the wrong patient's do-not-resuscitate order. Another patient was approved for surgery based on the wrong patient's record and was found dead in his hospital room the next day; and an infant was given expressed breastmilk from the wrong mother, who was infected with hepatitis. Ninety-one percent of mix-ups for which a harm score was reported were caught before the patient was harmed. About 13% of identification errors occurred at registration, when, for example, duplicate records were mistakenly created or two patients' records were "overlaid." Errors may result from the fact that some registration systems are not able to recognize minor variations in the spelling of names, according to William Marella, executive director for operations and analytics at ECRI Institute Patient Safety Organization. "Mary Ellen Smith, Mary E. Smith and Mary-Ellen Smith might all appear to be different patients," Marella said in the article. More than one-third of mix-ups involved diagnostic work and 22% involved treatments and procedures. Suggestions offered by ECRI Institute's report include adopting standardized protocols for patient identification and emphasizing the importance of the protocols to staff. Other suggestions include standardizing how names and other patient data are displayed in electronic health records and including patient photos. Currently only 20% of hospitals use patient photos, the article said. Clinicians should also ask patients to state their name—not just confirm it—and identify patients by two unique identifiers rather than by room number, which can easily change. "I think we are making good progress," said Dr. Lucian Leape, quoted in the article. "But a report like this brings us up short and shows us how far we need to go."

HRC Recommends: Because wrong-patient mistakes have multiple causes, there is no single solution for prevention. Risk managers and patient safety professionals must work with their organizations to develop multipronged strategies for safe patient identification. As a first step, organizations can use HRC's self-assessment questionnaire, listed in HRC Resources, to identify the strengths and weaknesses of their patient identification practices and to target improvement initiatives.

Topics and Metadata


Culture of Safety; Health Information Technology; Quality Assurance/Risk Management; Pharmacy


Ambulatory Care Center; Ambulatory Surgery Center; Assisted-living Facility; Behavioral Health Facility; Dialysis Facility; Emergency Department; Endoscopy Facility; Home Care; Hospice; Hospital Inpatient; Hospital Outpatient; Imaging Center; Physician Practice; Rehabilitation Facility; Short-stay Facility; Skilled-nursing Facility; Substance Abuse Treatment Facility; Trauma Center

Clinical Specialty



Allied Health Personnel; Clinical Laboratory Personnel; Clinical Practitioner; Dentist; Health Educator; Nurse; Patient Safety Officer; Patient/Caregiver; Pharmacist; Quality Assurance Manager; Risk Manager

Information Type


Phase of Diffusion


Technology Class


Clinical Category



SourceBase Supplier

Product Catalog


ICD 9/ICD 10






Publication History

​Published September 28, 2016

Who Should Read This

​Accreditation coordinator, Administration, Chief medical officer, Diagnostic imaging, Home care, Information technology, Laboratory, Long-term care services, Nursing, Outpatient services, Patient safety officer, Pharmacy, Quality improvement, Risk manager