September 28, 2016 | Aging Services Risk, Quality, & Safety Guidance
Resident safety hinges on delivering care and services to the right person (Phillips et al.). A fundamental and essential component of providing safe care is ensuring correct resident identification.
Although much attention has been devoted to the potential for patient misidentification in acute care hospitals where a wide range of patient interventions occur in various settings, residents of aging services organizations are also at risk of misidentification, particularly residents who have deficits in cognition, memory, hearing, speech, or vision or who face other communication barriers.
Residents with the same last name or similar sounding names and married residents with the same last name who reside in the same room may be at increased risk of resident misidentification.
Even in aging services organizations, where most residents identify the community as their home and are known to staff, the risk of misidentification is present because of staff changes from turnover and the use of temporary staff. The problem may be greatly exacerbated on weekends when many organizations rely on per diem and agency staff who are unlikely to know the residents.
Also, despite staff members' familiarity with the organization's residents, identification errors can still occur when a staff member inadvertently pulls the wrong resident's record—for example, to enter a medication order or to check on a resident's dietary needs.
As more organizations offer short-stay programs for patients needing care after a hospital stay, the risk of identification errors increases. Staff in short-stay facilities have less time to get to know a patient and cannot rely on their familiarity with patients to correctly identify them.
Many patient and resident identification mistakes are caught before care and services are provided, but reports submitted to ECRI Institute...