The Case

Mr. A was a 78-year-old man admitted with non-ST elevation myocardial infarction with acute kidney injury for whom medical management was chosen due to his multiple comorbidities. The patient's code status was DNR (do not resuscitate). Mr. B was a 62-year-old man admitted to the same medicine unit with hypoglycemia and a diabetic foot ulcer. He had a past medical history of ischemic cardiomyopathy. At 1:00 AM, the nurse found Mr. A unresponsive. The medicine intern was notified and pronounced Mr. A dead.

The intern went to the counter of the floor's central nursing unit to complete the death certificate and to notify the next-of-kin. The unit clerk usually put the death certificate folder on the counter next to the deceased patient's chart. This time, the chart next to the death certificate was Mr. B's chart. The intern grabbed Mr. B's chart, mistakenly believing that this was Mr. A's chart, and looked at the contact information on the front sheet. He called the number and notified Mrs. B that her husband had died. After erroneously notifying Mrs. B, he shifted his focus to completing the death certificate. It was at that point that he discovered that he had the wrong chart. He called Mrs. B back immediately, about 20 minutes after the previous call. Unfortunately, Mrs. B had called her children and let them know that their father had died. The intern apologized to Mrs. B and let her speak to her husband to reassure her. He then called Mrs. A and notified her about the death of her husband.

After being notified of the error, Mrs. B and her children were distraught after experiencing 20 minutes of thinking that their beloved husband/father had died.

The Commentary

This case is an unusual example of a wrong patient error, but similar errors have occurred. For example, in a hospital in the United Kingdom, a nurse, intending to call the family of a dying patient, called the wrong family because the next-of-kin details for a different patient had been mistakenly put into the dying patient's chart.(1) As a result of this error, the dying patient's family never received an update regarding the patient's rapidly deteriorating health, and they missed the opportunity to say goodbye.

Wrong patient errors are omnipresent in health care and have been made by physicians, physician assistants, nurses, nurse practitioners, and pharmacists; they have occurred in hospitals, emergency rooms, physicians' offices, pharmacies, and nursing homes.(2-4) Examples of wrong patient errors include medications, radiology tests, and laboratory tests ordered for the wrong patient, as well as operations, radiation treatments, and blood products administered to the wrong patient.(2,5-7) The damage caused by wrong patient errors may vary but can be profound—the above case was clearly traumatic for Mr. B and his family—and there are other examples of wrong patient errors that led to death.(8)

Although there are no published reports quantifying how often wrong family members are contacted, the frequency of wrong patient errors can be appreciated by looking at medication errors. The Table shows the rate of wrong patient medication errors using three different error detection methods.

No simple fix will prevent all wrong patient errors. We need safeguards for validating patient identification throughout health care processes. The World Health Organization (WHO) and The Joint Commission have recommended strategies for reducing the risk of wrong patient errors based on expert consensus and analyzing reports on the results of interventions from individual facilities.(9) The recommended strategies are:

• Emphasize the primary responsibility of health care workers to check patient identity before care is administered.
• Promote standardized approaches to patient identification among different facilities within a health care system.
• Provide clear protocols for identifying patients who lack identification (i.e., patients carrying no identifying materials admitted with altered mental status) and for distinguishing the identity of patients with the same name.
• Recommend labeling of containers used for blood and other specimens in the presence of the patient.
• Incorporate procedures that verify a patient's identity into training, orientation, and continuing education for all health care workers.
• Educate patients on the importance and relevance of correct patient identification.
• Encourage patients to participate in the identification process.

These recommendations represent a common sense approach to preventing many wrong patient errors and have been embedded into workflows where there is high probability of misidentification errors. Double-checking identification is a crucial safeguard built into both the Joint Commission Universal Protocol and the WHO Surgical Safety Checklist. Today, phlebotomists are taught to double-check two patient identifiers before drawing blood, as are radiology technicians before taking portable radiographs and nurses before giving medications.

However, double-checking identification will not solve all wrong patient errors. Providers interact with patients thousands of times a day in a wide variety of ways, and it is not reasonable to expect that every interaction start with an identification double check. In fact, in one study, human factors engineers created a simulated ordering environment with an alphabetical list of patients and asked 25 providers to place test orders.(10) The researchers intentionally gave patients similar sounding names and used an eye tracking device to check where providers looked prior to placing orders. None of the providers looked at the second identifier when selecting patients from a pick list, even when two patients had the same last name and similar first names (i.e., Jessie Torres and Jessica Torres).

The real promise of wrong patient error reduction lies with innovative technology solutions. For example, blood unit bar coding was shown to prevent 11.2 misidentification transfusion errors per every 100,000 transfusions.(7) Prominently displaying patient photographs in a computerized physician order entry (CPOE) system reduced wrong patient orders by 75%.(11) A system that required providers confirm the patient identification prior to placing orders in a CPOE system, by reentering the patient's initials, gender, and age, reduced wrong patient errors by 41%.(2) Another promising strategy used automated decision support to check that the medication indications match with patient's problem list.(12) Making wrong patient errors a rare type of error will likely require a combination of approaches.

The error in this case may have been averted if the chart was electronic instead of paper, and if the patients' pictures were prominently displayed on every screen. Several available electronic health records already have the capability to include patient photos in the medical record, although it is not yet known how often this feature is used. Had the resident seen a picture of Mr. B instead of Mr. A in the record, he may have realized his error. Moreover, if the death certificate could be completed within the electronic record, additional safety guards could be used, such as verifying the resident was on the correct patient by displaying the patient's photograph and reentering patient identifiers.

Electronic systems are not without issues and can be a contributing factor in some types of errors. In 2011, the Institute of Medicine (IOM) published a report titled Health IT and Patient Safety: Building Safer Systems for Better Care, which expressed deep concerns about the public health risk posed by the rapid implementation of health information technology.(13) Although the report noted that there is little published evidence quantifying the magnitude of the risk, the report specifically cited wrong-patient orders commonly arising from the "pick list problem," introduced by electronic medical records (EMRs), where clinicians select patients from long lists containing similar names in alphabetical order. In addition, many safety experts fear that EMRs that allow multiple patient records open at once are hazardous and increase the risk of wrong patient errors.

Completely eliminating wrong patient errors will be a long journey. Health care is just at the beginning of this journey, but it's moving in the right direction.

Take-Home Points

• Wrong patient errors are omnipresent in health care and require comprehensive preventive strategies.
• Several electronic interventions have been shown to prevent wrong patient errors, including bar coding, patient photographs, and re-verifying patient identification prior to placing orders.
• Hospitals should consider adopting bar coding, patient photographs, and patient re-verification within existing workflows.
• Significant error reduction will likely require a combination of approaches.
• More innovated solutions are needed, with rigorous research methodologies evaluating their effectiveness.

Jason Adelman, MD, MS Patient Safety Officer Montefiore Medical Center Bronx, NY

References

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3. Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Medication error reporting in nursing homes: identifying targets for patient safety improvement. Qual Saf Health Care. 2010;9:218-222. [go to PubMed]

4. Cohen MR, Smetzer JL, Westphal JE, Comden SC, Horn DM. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc (2003). 2012;52:584-602. [go to PubMed]

5. Kalapurakal JA, Zafirovski A, Smith J, et al. A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. Int J Radiat Oncol Biol Phys. 2013;86:241-248. [go to PubMed]

6. Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg. 2007;246:395-403. [go to PubMed]

7. Nuttall GA, Abenstein JP, Stubbs JR, et al. Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors. Mayo Clin Proc. 2013;88:354-359. [go to PubMed]

8. ISMP Medication Safety Alert! Acute Care Edition. Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside. March 10, 2011;16:1-4. [Available at]

9. WHO Collaborating Centre on Patient Safety Solutions: Patient Identification. World Health Organization, Joint Commission International, Joint Commission; May 2007. [Available at]

10. Henneman PL, Fisher DL, Henneman EA, et al. Providers do not verify patient identity during computer order entry. Acad Emerg Med. 2008;15:641-648. [go to PubMed]

11. Hyman D, Laire M, Redmond D, Kaplan DW. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics. 2012;130:e211-e219. [go to PubMed]

12. Galanter W, Falck S, Burns M, Laragh M, Lambert BL. Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). J Am Med Inform Assoc. 2013;20:477-481. [go to PubMed]

13. Health IT and Patient Safety: Building Safer Systems for Better Care. Committee on Patient Safety and Health Information Technology, Board on Health Care Services, Institute of Medicine. Washington, DC: National Academies Press; 2011. ISBN: 9780309221122.

14. MEDMARX 5th Anniversary Data Report: A Chartbook of 2003 Findings and Trends 1999–2003. Rockville, MD: United States Pharmacopeia Convention, Inc.; 2004.

15. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114-2120. [go to PubMed]

Table

Table. Frequency of wrong patient medication errors using three different methods of error detection.