A 575 bed teaching hospital, Children's Hospital Colorado handles roughly 16,000 admissions, 10,000 observation cases, 600,000 outpatient visits, and 160000 emergency department/urgent care visits each year. The hospital has a single EHR throughout all of its facilities and since 2007 has used the system for all provider order entry and clinical documentation. The EHR is also used by 8 affiliated primary care pediatric practices with 64 providers.
The impetus for this program came in 2009, when organizational leaders responded to a number of errors and near misses caused by patient misidentification that were reported through the hospital's voluntary reporting system. These reports convinced organizational leaders of the need to make reducing these errors a top priority for 2010. At the same time, these leaders engaged in a major effort to encourage staff to report any and all errors and near misses specifically related to patient identification problems, with the hope that such information would provide both baseline data on the magnitude of the problem along with information that could be used to determine root causes and potential solutions.
Patient misidentification is not a problem unique to Children’s Hospital Colorado. In 2016, a survey of 503 nurses, physicians, IT practitioners, and CFOs/financial operations experts found that 86 percent of respondents have witnessed or known of a medical error resulting from patient misidentification. According to 63 percent of respondents, incorrect identification of patients at registration is the primary root cause.5