"Wrong-patient" errors are not uncommon and such mistakes may have deadly consequence, according to a new report.
Researchers from ECRI Institute, a nonprofit group focused on patient safety, examined more than 7,600 cases of wrong patient errors recorded between January 2013 and June 2015 at more than 181 facilities. They concluded that these instances, which were reported voluntarily without fear of malpractice repercussions, represent just a small portion of such errors. More than 90 percent of the mistakes were detected before patient harm occurred, according to the report, but two were fatal and others may have had similar consequences had they not been caught.
Examples included a patient who was given another’s hypertension medication at 10 times the normal dose; a patient who was not supposed to eat but was brought the wrong meal tray and nearly choked; and an infant that was infected by hepatitis after being given breast milk from the wrong mother, according to the report. One patient was not resuscitated in the operating room because doctors pulled up the wrong health record, which included a do-not-resuscitate order, according to the report.
"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," William Marella, the institute’s executive director of PSO operations and analytics, said in an announcement. "We've seen that anyone on the patient's healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists and transporters."
About 13 percent of the identification errors were made during patient registration, according to the report, and 22 percent occurred during procedures and tests. Patients’ wristbands were at times missing, unreadable or not even checked at all.
The idiosyncrasies of electronic medical records also contributed to the problem, according to the report, as EMRs may not recognize minor variations in name spellings, which can lead to duplicate patient files or the blending of data for two individuals. ECRI suggested that data-sharing among health IT systems may also be a contributing factor.
ECRI recommended that hospitals use more standard means of patient identification, which should include photographs with patient files. Clinicians and hospital leaders also should discuss potential identification errors more openly to prevent patient harm, the report's authors said.