Safety of care
A is for alias—Getting the right care to the right patient
Originally published December 2014
Patient misidentification is common and can occur in areas such as medication administration, blood product transfusions, diagnostic testing, and patient procedures. Harm to patients and near misses are among the possible results.
A review of the CMPA's experience with issues of misidentification found 54 cases during the seven year period from 2007-2013. The majority were legal actions. Specialties at highest risk were radiology, family practice, and pathology. The common themes in these cases include patients with the same or similar names and results from the same tests performed at different times.
Case examples: Right patient, right test, wrong date
A previously healthy, 52-year-old female is admitted to hospital for the treatment of newly diagnosed acute myelogenous leukemia, which was confirmed by a bone marrow biopsy. Induction chemotherapy is initiated. Despite appropriate antibiotics and antifungal treatment, the patient subsequently develops pancytopenia and persistent pyrexia.
Two weeks later, a repeat bone marrow is performed to assess the need for further treatment. The following day the attending hematologist visits the pathology department to review the findings. By mistake, he is directed to the pathologist who had interpreted the first biopsy two weeks previous. The hematologist requests an interpretation of the marrow biopsy but does not specify the date of the investigation. Recognizing the patient's name, the pathologist replies that the biopsy had shown acute leukemia. On this basis, a second course of chemotherapy is ordered. However the second marrow biopsy shows no evidence of leukemia.
Several weeks later the error is discovered and the hematologist discloses what has happened to the patient and her family, and offers an apology. Unfortunately, the patient develops pancytopenia and dies of an intracranial hemorrhage six weeks after admission.
The matter is deemed indefensible and a settlement is paid to the patient's family by the Association on behalf of the attending hematologist.
Early in the evening on the third day of a long weekend, a 42-year-old male presents to a walk in clinic with signs and symptoms suggestive of appendicitis. His only significant medical history is a cholecystectomy one year previously at a community hospital. The clinic physician contacts the on-call radiologist at the same community hospital and a CT scan is performed and filed in the PACS system (Picture Archive and Communication Systems). The radiologist, who had been on call all weekend, reviews the images and notes gallstones but no signs of appendicitis. The patient is discharged.
Two days later the patient returns with generalized peritonitis. A ruptured appendix is identified at surgery. When the radiologist is asked to review the initial CT scan, he quickly realizes there is clear evidence of appendicitis as well as a previous cholecystectomy, neither of which was mentioned in his report.
Puzzled as to the origin of the oversight, the radiologist analyses all of the patient's previous studies. An abdominal CT scan had been performed two years previously prior to the cholecystectomy. The radiologist concludes he had viewed and reported on this previous study rather than the current one.
In the subsequent legal action, the matter is deemed indefensible and a settlement is paid to the patient by the Association on behalf of the member physician.
Considerations for managing risks
It is important that physicians and healthcare workers are alert to the possibility of mix-ups and are vigilant in matching the correct patients with the correct care. At a superficial level, verifying a patient's identity appears to be a simple process. However, as these cases illustrate, additional measures may be needed to ensure that the right treatment is being administered to the right patient at the right time. Based on these cases, there are a number of strategies for keeping a patient safer.
Physicians should verify the patient's name and, if necessary, birthdate and unique numerical identifier before ordering an investigation or treatment, or viewing test results. In many instances in a clinic-based practice with outpatients, this information will not be included in an identity wrist band and must be sought elsewhere.
In a busy hospital environment, the likelihood of having two patients with the same last name is approximately 30%.1 In an emergency department, for example, it is not uncommon to have multiple family members being treated simultaneously after motor vehicle crashes. If there are patients with identical last names in a treatment area, if possible, avoid having them in the same room. It may be advisable to have some ‘flagging' system in place that will put either electronic or physical alerts on census sheets, addressographs, and patient records. Some organizations are exploring bar coding as a strategy.2
Allow patients to take part in their own risk management and further lessen the risk of a mix-up. If patients have a common name, speak with them and their family about the possibility of confusion with another patient and the need for staff to double check their identity. This will prompt most patients to question whether they are receiving the correct investigation and treatment. Be aware, however, that patients with visual, auditory, or cognitive impairments may not be capable of taking on this role and pose special challenges.
When performing tests, it is often necessary to confirm the identity of the patient as well as the date and time the test was performed. When interpreting results, check that the date and time of the investigation are the ones relevant to the care. While electronic data management systems provide a wealth of information, mix-ups can still occur.
Disclosure of harm to patients is required. Members with questions should not hesitate to call the CMPA for additional information and advice.
- Shojania, K. Agency for Healthcare Research and Quality Web M+M Rounds, February 2003. Accessed October 2014 from: www.webmm.ahrq.gov
- WHO Collaborting Centre for Patient Safety Solutions, "Patient Identification: Patient Safety Solutions," Volume 1, Solution 2, May 2007