Cases & Commentaries

Mistaken Identity

Commentary By Leslie W. Hall, MD

The Case

An 85-year-old Cantonese-speaking woman was
admitted to the medical service with altered mental status and a
reported fall. After finding tenderness in her left hip, the
physicians obtained plain films, which confirmed a nondisplaced
femoral neck fracture. The orthopedic surgery team was consulted
and, after evaluating the patient, decided that the patient's age,
comorbidities, and minimal pain and tenderness on exam made her a
candidate for conservative, nonsurgical treatment. These
recommendations were documented in her electronic health record,
where the team specifically noted: "We're reassured to see the
patient is able to weight-bear without pain, even though we
wouldn't suggest it in the short-term."

The following day, one of the medical interns
read the orthopedic surgeon's note and found these comments about
the patient ambulating odd. The patient had strict bed-rest orders
and was in significant pain, making it hard to believe that she had
been observed walking. After further investigation, the intern
realized that the orthopedic team had evaluated the wrong
patient—the patient's roommate, who also happened to be a
Cantonese-speaking elderly woman. The orthopedic surgery team was
consulted again and, after some embarrassment about their mistake,
offered surgical repair of the correct patient's fractured hip.

The Commentary

Correctly identifying a patient seems like a
straightforward task. However, as this case illustrates, a variety
of circumstances may contribute to patient identification errors
within complex health care systems. In some cases, incorrect
identification may lead primarily to provider embarrassment without
any patient harm. Several years ago, I spoke with a physician who
was visiting a newly admitted patient seeking treatment for
amphetamine addiction. After pulling the curtain around the bed to
create an atmosphere of privacy, he began to question the patient
about his history of drug use. When the patient denied such abuse,
the physician pressed harder, eventually getting the patient to
admit to using several illicit substances. As the patient grew
increasingly uncomfortable with the conversation, the patient in
the neighboring bed finally spoke up and said, "Doc, I think you're
supposed to be talking to me." Similar to the case presented, this
situation created awkward moments, but ultimately, both patients
received the care they required.

On the other hand, many instances of patient
identification errors lead to more than embarrassment—such
errors can lead to serious harm or even loss of life. These
identification errors may occur with phlebotomy, imaging studies or
other diagnostic testing, medication administration, delivery of
radionuclide agents, blood transfusions, chemotherapy
administration, surgeries, and other procedures.(1)

The exact frequency of health care
misidentification events is difficult to determine. The United
Kingdom Patient Safety Agency reported 236 incidents and near
misses in less than 2 years related to missing or incorrect
wristbands.(2) The
State of New York recorded 27 incidents of invasive procedures on
incorrect patients between April 1998 and December 2001.(3)
Practitioners in Florida reported 63 wrong-patient surgical
procedures between 1990 and 2003.(4)
About 0.1% of blood product administrations are associated with an
error, with misidentification of the blood recipient accounting for
about two thirds of these errors.(5) As
reporting systems are often subject to underreporting (3),
the real magnitude of this problem is probably greater than these
data reflect.

Several patient characteristics may increase
the chance of misidentification. Neonates and small children are
unable to identify themselves to providers, and family members may
not always be present to assist in this process.(6) Communication difficulties caused by dementia increase
risk of misidentification in these patients (7); patients with impaired cognition from critical
illness, medication effects, or developmental problems may have a
similar risk. Our case highlights the impact of language barriers
on the potential for patient identification errors. Furthermore,
limited English language proficiency, which has been reported in 8%
of the population, is also associated with increased risk of
serious medical events among both pediatric and adult hospitalized
All of these characteristics suggest a patient population that
could be targeted for prevention strategies.

Environmental factors may also increase the
likelihood of patient misidentification. Patients with the same (or
similar) names are often found within most health care systems,
with up to half of patients in some large systems sharing names
with one or more other patients.(10)
One study noted that identical surnames were present on 34% of
patient days in a neonatal intensive care unit.(11) Adding to the complexity, movement of patients from
one inpatient setting to another (e.g., transfer to a different
unit or facility) creates opportunities for confusion, as do the
growing number of provider handoffs that exist in hospital

Given all of the noted "risk factors" for
patient misidentification, a series of prevention strategies has
been outlined to mitigate the risk. First, simply checking a
patient's wristband to confirm identity is widely viewed as the
single most important strategy.(12)
Aligned with this step, actively engaging the patient to confirm
his or her name as well as a second identifier, such as date of
birth, is recommended by the Joint Commission as best
practice.(1) The
Table provides an example of passive and active patient
communication techniques, demonstrating the importance of using an
active process. In cases when a patient wristband is removed (e.g.,
for surgery or IV placement) or has fallen off (e.g., in a
neonate), additional steps to ensure correct patient identity are
warranted. One of the greatest barriers to recurrent patient
identification practices is provider concern that repeated checks
will alarm or annoy the patient. Many health care systems are
educating all patients and families that their ongoing emphasis on
confirming patient identity is part of a commitment to make care as
safe and confidential as possible.

Outside of such practices that rely on
provider vigilance, specific communication tools, adapted from crew
resource management (CRM) practices in aviation, have also been
used. For example, the Universal Protocol for Preventing Wrong
Site, Wrong Procedure, Wrong Person Surgery requires the use of a
"time out" (13) to
ensure that all team members are on the same page about the
procedure at hand, including assurance of proper patient
identification. Similar structured communication techniques and
checklists have also been applied outside of procedural areas to
improve safety and ensure correct patient identification. Such
structured identification and communication practices have been
adopted more readily by nurses (particularly in medication
administration) but are likely to be equally important in
preventing misidentification errors by physicians, as this case
vividly demonstrates.

From a technology solution standpoint, the use
of bar coding on patient wristbands already plays an integral role
in correct patient identification.(14)
Adding a patient's picture to the wristband may further improve
safety systems by reassuring providers that they are treating the
correct patient (Figure). The use of radiofrequency devices has also
been suggested as a future strategy for improving patient
identification, but such use is not yet widespread.(15) As with other aspects of patient safety, technology
will play a key role in improving patient identification systems
only if designed and implemented effectively.

Finally, awareness of language barriers should
alert providers of the need for an increased focus on proper
patient identification and extra attention to communication. If
English is a patient's second language, providers may overestimate
the amount of information the patient understands. Using
interpreter services and taking the time to confirm a patient's
understanding of health information will assist in preventing
patient misidentification. Ideally, a system—such as an
alert, a special designation on a wristband, or an easily
identifiable bedside prompt—would be created to assist
providers when caring for patients with language barriers.


The patient's experience in this
case highlights several important lessons about accurate patient

  • Patient identification errors occur
    at least occasionally in virtually every health system, and some
    lead to significant patient harm.
  • Certain patient factors such as young
    age or impaired sensorium increase the likelihood of
    misidentification. Use of two patient identifiers is considered
    best practice.
  • Using structured communication tools,
    such as a preprocedure "time out," is an effective method to ensure
    appropriate patient identification.
  • Technology solutions, including bar
    coding and radiofrequency devices, may offer additional protection
    against patient misidentification.
  • Language barriers may lead to
    misidentification and increase the likelihood of adverse events.
    Identifying patients with such barriers, devoting extra attention
    to communication, and developing systems for improved interpreter
    services may all serve as important patient identification

Leslie W. Hall, MD
Senior Associate Dean for Clinical Affairs
University of Missouri–Columbia, School of Medicine


1. The Joint Commission. Patient identification.
Patient Safety Solutions. 2007;1(Solution 2):1-4. Available at:

2. National Patient Safety Agency. Wristbands for
hospital patients improves patient safety. Safer Practice Notice
11. 2005:1-6. Available at:

3. Chassin MR, Becher EC. The wrong patient. Ann
Intern Med. 2002;136:826-833. [go to

4. Seiden SC, Barach P. Wrong-side/wrong-site,
wrong-procedure, and wrong-patient adverse events: are they
preventable? Arch Surg. 2006;141:931-939. [go to

5. Pagliaro P, Rebulla P. Transfusion recipient
identification. Vox Sang. 2006;91:97-101. [go to

6. Gray JE, Goldmann DA. Medication errors in the
neonatal intensive care unit: special patients, unique issues. Arch
Dis Child Fetal Neonatal Ed. 2004;89:F472-F473. [go to

7. Miller CA. Communication difficulties in
hospitalized older adults with dementia. Am J Nurs. 2008;108:58-66.
[go to

8. Cohen AL, Rivara F, Marcuse EK, McPhillips H,
Davis R. Are language barriers associated with serious medical
events in hospitalized pediatric patients? Pediatrics.
2005;116:575-579. [go to

9. Bartlett G, Blais R, Tamblyn R, Clermont RJ,
MacGibbon. Impact of patient communication problems on the risk of
preventable adverse events in acute care settings. CMAJ.
2008;178:1555-1562. [go to

10. Lee AC, Leung M, So KT. Managing patients
with identical names in the same ward. Int J Health Care Qual Assur
Leadersh Health Serv. 2004;18:15-23. [go to

11. Gray JE, Suresh G, Ursprung R, et al. Patient
misidentification in the neonatal intensive care unit:
quantification of risk. Pediatrics. 2006;117:e43-e47. [go to

12. Beyea SC. Systems that
reduce the potential for patient identification errors. AORN J.
2002;76:504-506. [go to

13. The Joint Commission. Universal protocol for
preventing wrong site, wrong procedure, wrong person surgery.
Available at:

14. Murphy MF, Kay JD. Barcode identification for
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15. Kondro W. American Medical Association boards
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Table. Comparison of Passive and Active
Communication Techniques for Confirming Patient

Passive Communication Active Communication

Physician: Good morning, Mrs. Jones. I'm sorry to awaken you. My
name is Dr. Brown, and I'm from the Orthopedic Department. Your
physician asked that I stop by to visit with you and briefly
examine you this morning.

Patient: Okay.

Physician: Good morning; I'm sorry to awaken you.

Patient: That's okay.

Physician: My name is Dr. Brown from the Orthopedic Department.
Can I take a moment and ask you to confirm your name? [Looks at
name band.]

Patient: I'm Sarah Jones.

Physician: And can you confirm your date of birth for me?
[Still looking at name band.]

Patient: March 4, 1936.

Physician: Thank you, Mrs. Jones. We always like to make sure
we're talking to the right patient before we begin to discuss
important medical information. Is this a good time to visit with
you about your recent fall and hip injury?

Patient: It's fine, doctor.


Figure. Example of patient wrist band using
patient name, date of birth, bar coding, and patient photo as aids
to proper patient identification.