The nature and occurrence of registration errors in the emergency department.
Approach to Improving Safety
Setting of Care
This study describes several instances of near misses that occurred due to patient misidentification, such as physicians being unable to access previous test results because—unknown to them—the patient had been assigned a second medical record number. The investigators used human factors analysis to identify the underlying systems issues that contributed to these errors. Previous studies in adult and pediatric inpatients have also identified patient misidentification as a potential contributor to a large number of errors.