Accreditation

ECRI: Most wrong-patient errors are preventable

Accreditation Insider, September 27, 2016

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Despite the onset of electronic medical records and other ways of identifying patients, wrong-patient procedures still occur with distressing frequency. In a newly published analysis, the ECRI Institute reviewed 7,600 wrong-patient events in 181 hospitals. Roughly 9% of those errors resulted in a patient being hurt or dying, despite the fact that most of the identification mistakes were preventable.

 "Although many healthcare workers doubt they will actually make a mistake in identifying their patients, ECRI Institute [Patient Safety Organization (PSO)] and our partner PSOs have collected thousands of reports that show this isn't the case," says William M. Marella, MBA, MMI, ECRI Institute executive director of PSO Operations and Analytics. "We've seen that anyone on the patient's healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists, and transporters."

Despite the onset of electronic medical records and other ways of identifying patients, wrong-patient procedures were still the second most frequently reported Sentinel Event in 2015.  The ECRI report said the big drivers of patient mix-ups are increased patient volume, multiple handoffs, and interoperability issues between IT systems. The report also found:

•    “Incorrect patient identification can occur during multiple procedures and processes, including but not limited to patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and emergency care.”
•    “Patient identification mistakes can occur in every healthcare setting, from hospitals and nursing homes to physician offices and pharmacies.”
•    “No one on the patient's healthcare team is immune from making a wrong-patient error.”
•    “Many patient identification errors affect at least two people. For example, when a patient receives a medication intended for another patient, both patients—the one who received the wrong medication and the one whose medication was omitted—can be harmed.”

The Joint Commission launched its “Speak Up™: Right ID, Right Care” campaign on May 6, focusing on the importance of dual identifiers in healthcare. The accreditor’s press release contains an animated video, podcast, and infographic that are free for download and reuse. Click here to visit the “Speak Up™: Right ID, Right Care” page.



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