Accreditation

Q&A: Patient misidentification

Briefings on Accreditation and Quality, November 1, 2018

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 Patient misidentification is an underreported problem that still plagues healthcare. Despite electronic records, bar codes, and checklists, many patients end up getting the wrong procedure, medicine, care, or diagnosis. 

Brad Truax, MD, is board-certified in both neurology and internal medicine, and has more than 20 years of experience in medical administration and patient safety. He spoke with BOAQ about patient mix-ups: why they still happen and what can be done to stop them. 

This Q&A has been lightly edited for clarity. 

Q: Why do facilities still struggle with patient ID mix-ups? It seems like it would be an easy thing to solve.

Truax: Sounds like it ought to be easy, but there’s two main problems: the name problem and the IT problem. They’re the biggest reasons we haven’t been able to solve this.

The [statistics on] people with similar names is pretty astonishing. There’s one study where they looked at patients in a ward over a three-month period; they found that on at least a third of the days there were at least two people with the same last name. In the [neonatal ICU], it’s even more frequent. 

For a number of years now through Joint Commission, we’ve gone to two-factor identification. And in most places, that’s the first and last name plus the date of birth (DOB). But it’s still possible to have [patients with] both.

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