Adverse events as a consequence of medical treatment are now recognized to be a significant source of morbidity and mortality around the world (World Health Organization [WHO], 2005). Somewhere between 3 and 5% of all hospital admissions in the United States result in an adverse event, and in 1999 it was estimated that the majority of the 44,000 to 98,000 deaths caused annually by medical mistakes could have been prevented (reviewed by Leape, 2000, and WHO, 2005).
The sources of adverse events can be divided into clinical practice, defective or poorly maintained products, improper procedures, or an organizational system. The World Health Organization (2005) concluded that systemic failures are the primary source of adverse events, and can be attributed to a particular organization's patient care strategy, culture, attitudes toward managing quality of care and risk prevention, and the ability to learn from mistakes. In other words, the work environment plays a dominant role in determining the prevalence of adverse events for a particular organization. For example, if an organization punishes employees for reporting mistakes, then mistakes won't be reported and corrective actions can't be taken to prevent future mistakes. Negligence or a lack of proper training was found to be relatively minor causes of adverse events when compared to an organization's system of operation, but negligence is still responsible for approximately 30% of all adverse events in U.S. hospitals (reviewed by Brady et al., 2009). One of the primary concerns regarding negligent practice is patient misidentification, which can potentially result in a number of catastrophic outcomes for the patient.
The Recognized Importance of Correct Patient Identification
The first goal listed in the Hospital National Patient Safety Goals for hospital accreditation by The Joint Commission, the primary hospital accrediting agency in the United States, is correct patient identification (The Joint Commission, 2010). The Joint Commission recommends using at least two patient identifiers at the bedside, which can include the following:
Patient Identifiers March 17, 2011
Medical record number
Or another form of identification specific to the patient.
A patient's bed or room number should not be used to identify a patient for purposes of administering medications or transfusions, taking laboratory specimens, processing patient admission and discharge, transporting to surgery, another clinic, or hospital, or any other procedure that could potentially harm a misidentified patient. Whenever possible, a patient should be positively identified with at least two identifiers in the patient's presence. This procedure applies to the labeling of laboratory specimen containers.
The Association of Surgical Technologists (2006) published a white paper recently, elaborating further the proper procedures for correctly identifying patients. In addition to the two or more identifiers recommended above, the following can also be used to establish the patient's identity:
Date of birth
Social security number
The recommended times for confirming the patient's identification are during the scheduling of surgery, when transferring a patient to another location, prior to sedation, and prior to entry into the operating room. Wrist band information should match the patient's chart and transfer slip, and when possible a verbal confirmation should be received from the patient or authorized representative regarding the surgical procedure(s) to be performed.
Two perioperative 'time outs' are also recommended (Association of Surgical Technologists, 2006). The first should occur immediately prior to bringing the patient into the operating room, for the purpose of having the patient state their name, social security number or date of birth, and site of surgical procedure. This information should be matched to the patient's wristband, informed consent, and operating room schedule. The second time out should occur in the operating room just prior to the start of the surgical procedure, and involves a verbal confirmation of patient identity, procedure, location, and when applicable, implants.
In situations where the patient is unable to provide verbal confirmations of identity, a family member or designated representative can confirm the patient's name, the procedure(s) to be performed, and the location of the surgery (Association of Surgical Technologists, 2006). If the patient is a minor, the patient's identity and surgical procedure should be confirmed with both the child and parent or legal guardian. All patients should wear a wristband or bracelet that provides positive identification, and hospital wristbands, if removed during surgery, should be kept with the patient's chart and placed back on the patient immediately after surgery. It should also be emphasized that wristbands shouldn't be considered an acceptable substitute, under normal circumstances, for the two or more patient identifiers recommended by The Joint Commission (2010).
Special Care is Emphasized for Transfusions
The Joint Commission provides additional instructions for positively identifying a patient prior to initiating a blood transfusion (The Joint Commission, 2010). A two person team is recommended and at least one member should be the person that will conduct the transfusion. The second member should be qualified to conduct a blood transfusion. When an automated patient identification system is available, this can substitute for the second team member.
Both members of the team should positively identify the patient using at least two identifiers. The blood to be transfused should be matched to the order and the patient should be matched to the blood component. A similar approach has been used by nursing staff when administering medications in hospitals in England (Duxbury et al., 2010).
The Prevalence of Patient Identification Errors and Associated Adverse Events
Obtaining accurate measures of the prevalence of patient misidentification is difficult. People in general are typically unwilling to admit to having made a mistake, and in some hospitals, doing so could elicit sanctions. In spite of this limitation, researchers have attempted to determine how often patients are misidentified, and how often this results in an adverse event, by examining specific services or procedures that take place in a hospital setting.
Misidentification of Laboratory Specimens
In a study of venous blood specimen collection procedures in Sweden, 9.6% of the nurses, psychiatric orderlies, and laboratory technicians failed to ask the patient their name or identification number (Wallin et al., 2010). Another 17% failed to check patient identity because they personally knew the patient, 43% relied on the patient's ID card, and 79% failed to check patient wristbands.
In a study of laboratory specimen identification errors conducted within the United States (Valenstein, Raab, and Walsh, 2006), 0.0324% of samples were found to be misidentified prior to sample verification, and 0.0055% of misidentified samples made it through the verification process and were released to the patient's physician. Of the misidentified laboratory results released, 1 in 18 resulted in an adverse event. Based on these results, the authors estimated that close to 160,000 adverse events are caused by misidentification of patient laboratory specimens each year.
Valenstein, Raab, and Walsh (2006) found a significant inverse relationship between the number of preverification and postverification errors (p < 0.001) for a subset of the laboratories included in their study of specimen misidentification. This result was interpreted as being symptomatic of stringent patient safety protocols that resulted in higher rates of catching specimen misidentification errors early in the process. The variability in laboratory quality based on this measure was considerable, ranging between 30 and 95% of misidentified samples being caught before release. Over 50% of misidentification error was due to mislabeling of the primary specimen, and 22% was due to computer registration and order entry errors.
Another study examining the prevalence of laboratory specimen errors, found that approximately 0.1% of laboratory samples were either mislabeled (8.4%), unlabeled (38.6%; missing one or more of the two required patient identifiers), or represented a mismatched requisition (52.9%; Wagar, Tamashiro, Yasin, Hilborne, and Bruckner, 2006). Intensive care units generated twice as many specimen errors as other clinics, which the authors suggested was the result of working in a more complex care environment. Patient safety initiatives were introduced during the two-year period of the study and the category of labeling errors that improved the most was mislabeling (p < 0.001), from an average of about 21 errors per month to less than 1. The authors of this study believed mislabeling errors represented the greatest threat to patient safety because they are the hardest to detect and because the actual prevalence for this type of error is unknown.
Misidentification during Blood Transfusions
The prevalence of labeling error identified by a blood transfusion service in Scotland was examined by researchers (Ibojie and Urbaniak, 2000), but instead of counting only incidences resulting in mistransfusions, the researchers also counted the number of labeling errors that were detected before any harm could be done to the patient (near misses). The rate of mistransfusions was 1 out of 27,007 units of blood supplied, but when near misses were also counted the rate was four times as high at 1 out of 6,752 units. Notably, 23 out of 28 errors recorded during the study period were related to improper identification of the blood donor or recipient (n = 16) or mistakes in labeling the specimen (n = 7). Only 5 errors occurred…