September 23, 2016 | Healthcare Risk, Quality, & Safety Guidance
Patient safety hinges on delivering care to the right person throughout the continuum of care (Phillips et al.). Yet, the risk of wrong-patient errors is ever-present for the multitude of patient encounters occurring daily in all types of healthcare settings.
Although many patient identification mistakes are caught before care is provided, others do reach the patient, leading to wrong-person procedures, medication errors, transfusion mistakes, diagnostic testing errors, and more. Some wrong-person mistakes can have fatal consequences. ECRI Institute PSO recently conducted an analysis of wrong-patient events submitted by its member and collaborating organizations. In one tragic case submitted to the PSO's event report database, a patient in cardiac arrest was mistakenly not resuscitated because the care team pulled up the wrong patient's record and adhered to a different patient's do-not-resuscitate (DNR) order. (ECRI Institute PSO)
In addition to their potential to cause serious harm and even death, patient identification errors are particularly troublesome for a number of other reasons; see Why Pay Attention to Patient Identification?
No studies have identified the overall incidence of wrong-patient errors in healthcare settings, although numerous articles describe the extent of the problem for various healthcare processes. Consider the following information from published reports:
Incorrect patient identification can occur during multiple procedures and processes, including but not limited to patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and emergency care.
Patient identification mistakes can occur in every healthcare setting, ranging from hospitals and nursing homes to physician offices and pharmacies.
No one on the patient's healthcare team is immune from making a wrong-patient error. Mistakes can be made by physicians,...