Wrong-patient Errors Can Lead to Death, But They Can Be Prevented

By Joy Daughtery Dickinson, Executive Editor, AHC Media

About 9% of the wrong-patient events studied for a just-released report led to temporary or permanent harm or, in some cases, death. Most, if not all, of such patient identification errors are preventable, according to an analysis of patient safety errors from ECRI Institute PSO in Plymouth Meeting, PA.

There are several factors in healthcare that may contribute to wrong-patient errors, including increasing patient volume, frequent handoffs among staff, and increasing interoperability and data sharing among IT systems.

“Although many healthcare workers doubt they will actually make a mistake in identifying their patients, ECRI Institute PSO and our partner PSOs have collected thousands of reports that show this isn't the case,” said William M. Marella, MBA, MMI, ECRI Institute executive director of PSO operations and analytics, in a released statement. “We've seen that anyone on the patient's healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists, and transporters.”

The report found the following:

• Incorrect patient identification can occur in many places and during many processes. Some of them include patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and ED care.
• Patient identification mistakes can occur in every setting, including hospitals, nursing homes, physician offices, and pharmacies.
• No one is immune from making a patient identification error.
• Many of these errors affect at least two people.

ECRI Institute PSO gives this example: When a patient receives a medication intended for another patient, both of them can be harmed. ECRI Institute PSO reviewed more than 7,600 wrong-patient events occurring over 32 months in 181 healthcare organizations. The events might represent only a small percentage of all wrong-patient events occurring, according to the Institute. (To access the report, which is free with registration, click here. For more information on this topic, see upcoming issues of Healthcare Risk Management and Hospital Access Management.)