Ask HRC: Preventing Patient Misidentification in Radiology

September 26, 2013 | Healthcare Risk, Quality, & Safety Guidance


A Healthcare Risk Control (HRC) System member asked for help regarding best practices for patient identification when performing diagnostic imaging exams. Specifically, the member asked if HRC was aware of any devices, such as barcode scanners, being used to verify a patient’s identification for radiology.

Although we were unable to find any articles in the published literature on the use of devices to verify a patient’s identification before imaging procedures, an article published in the June 2011 Pennsylvania Patient Safety Advisory from the Pennsylvania Patient Safety Authority addresses errors in radiology and indicates that about 30% of the radiology events reviewed involved patient misidentification. Those misidentification events consistently noted that the error was the result of the failure to use two distinct patient identifiers (e.g., the patient’s name, date of birth) as recommended by the Joint Commission National Patient Safety Goal for patient identification. Errors occurred when the patients were identified using room numbers (which could result in an error if, for example, the patient was moved to another room) or the intended procedure (which could result in an error since more than one patient may be undergoing a particular type of exam, such as an ultrasound study). The goal prohibits using the patient’s room number or physical location as an identifier. Sometimes errors occurred when patients were asked to passively confirm their name (“Are you...

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