In your neighborhood, “keeping up with the Joneses” may be a common pursuit, or maybe you are right on the heels of those Smiths or Johnsons. While being a subject of a trivial idiom in this context is harmless, having a last name like Jones, Smith, or Johnson could be enough to catapult you into a medical mistake nightmare. Especially for patients with common last names, incorrect identification in hospitals and other healthcare settings has become a serious concern.
Recently, the ECRI Institute Patient Safety Organization reviewed 7,600 wrong-patient events over a 32-month timeframe and found that 9% of the identity mishaps caused direct harm or death to a patient. Patients trust care providers with their greatest gift—their life, itself—and these organizations must be proactive about safeguarding patient identity and accurate in their records matching. Reasons for the mix-ups and their timing are varied, but the burden of responsibility is on the healthcare provider.
Which Mrs. Smith are you?
As more health systems and independent practices go digital with patient records, there are more opportunities for slip-ups when transferring patient data. Often, front desk staff at a provider’s office will try to find a patient in the system by name or birthdate, but if there is not an exact match with the data being entered, the employee will simply create a new patient file. For example, Harris County Hospital District in Houston found 2,488 patients named “Maria Garcia” in their system, and 231 of them share the same birthdate.
Different Electronic Medical Record (EMR) systems often have different ways of filtering and presenting the same data. Some institutions use a middle initial, while some omit it or require spelling the middle name out. There is a frequent discrepancy on how systems handle suffixes such as “Jr.” or “Sr.” in a name, and hyphenated names. Additionally, basic clerical mistakes or mistypes—particularly in stressful or hurried circumstances—result in inaccurate data entry with social security numbers, birthdates, or name spelling. If a patient changed her last name due to marriage or divorce or moved, a staff member may not be able to locate her in the system.
When a “new” patient file is added to the records system, it now represents just a small portion of the patient’s medical information and history. Rather than consulting a complete medical record, a physician may be looking at a fragment of the patient data. If important health information is not included in the file, the patient’s health is at risk. One clear example is when an unconscious patient in critical condition is brought into the emergency department and hospital staff cannot confirm if he or she has a pre-existing condition or medication allergy. Creating a new patient record when no match is found in the system can do more harm than good in the long run.
Whose MRI shows cancer?
While creating duplicate records can create challenges of physicians acting on incomplete information, incorrectly attributing medical records to an individual can be even worse—leading physicians to make decisions for one patient based on another patient’s information. While patient registration and admittance challenges—especially in light of disparate EMR systems—are problematic, 72.3% of patient identification errors happen during clinical encounters, including diagnostic procedures such as surgical operations and general treatment.
In Massachusetts alone, there have been 14 instances from 2011-2016 during which care providers at facilities performed a procedure on the wrong patient, according to state records. One of these cases includes an investigation alleging a surgeon removed a kidney from the wrong patient based on what was seen in another patient’s scans.
While nurses, physicians, and other clinical staff members theoretically have protocols in place to check and confirm a patient by name or birthdate, these methods are often not foolproof to ensure the right patient is receiving the right service. The Patient Safety Network highlighted patient mix-ups at University of California San Francisco Medical Center and found that over a three-month period, inpatient services had two patients with the same last name on 28% of the days. Name or birthdate checking is simply not sufficient.
In addition to endangering patient safety, the occurrence of “the right procedure, wrong patient” is also a financial drain for hospitals. Redundant or unnecessary tests, incorrect diagnoses, incorrect provision of services, and unnecessary or lengthened hospitalizations increase hospital costs across the U.S. Patient misidentification costs hospitals an average of $17.4 million each year in denied claims.
The need for action
The development of a national patient identifier—tied specifically to every single patient—has been a desired course of action since (at least) the 1990s and the enactment of HIPAA. Logistical and financial challenges relating to interoperability and privacy have been hindrances ever since. The solution requires a method to validate and authenticate patient identity in a safe and secure manner.
Assigning a National Patient Identifier to each patient would ideally involve statistical matching and a referential database that is continually updated so providers can have the most confidence in the resulting records. The ability to assign national patient IDs that enable data sharing across systems, a key component for identity management, already exists. What are we waiting for?