Every time patients are misidentified, they are put at risk. Sometimes the harm is minor: an unnecessary test or being placed in the wrong room. And sometimes the consequences are dire: getting the wrong medicine or having the wrong operation performed. There are numerous points where a mix-up can happen, including at the front desk, during a room change, or during a poorly executed patient handoff.
Austin F. Mount-Campbell, PhD, is a patient safety fellow at the Center for Medical Product End-user Testing in the VA Pittsburgh Healthcare System. He’s done previous studies on the efficacy of patient ID wristbands and patient handoffs.
Q: Why do facilities still struggle with patient ID mix-ups? It seems like it ought to be easy to solve.
Mount-Campbell: It is a combination of issues, even to the point where different facilities have a different set of issues. Generally speaking, it’s related to facilities’ health information technology—either in their own poor design or in the poor integration into the technology ecosystem.
Many facilities also have issues with who is responsible for patient ID. Is it the person who checks in the patient? Is it the unit clerk? Is it the patient’s nurse?
Often, facilities don’t have consistent rules. Sometimes one unit does it one way and you walk down the hall to another unit and things are done differently.
Beyond that, HIPAA and patient privacy teams aiming to protect patient privacy often create unnecessary rules and restrictions that may hinder what might be commonsense solutions.
Q: Please tell me about your research on patient ID wristbands. What were the takeaways on the practice and how to improve it?
Mount-Campbell: My research was related to the accuracy of information on wristbands, why inaccuracies exist, and how we might make them more accurate.
I found as many as half of patient wristbands had misinformation on them, [but] I don’t want you to mistake misinformation as necessarily being dangerous or a patient safety risk; rarely would I consider that dangerous.
My major takeaways are on three levels. First, each facility should clearly identify who is responsible for patient wristbands in order to establish consistency and ownership.
Second, facilities need to remove information from wristbands that changes frequently (e.g., fall risk, which can change multiple times within a single day, meaning the wristband has to change and you’re adding an extra opportunity to introduce errors). This also creates overload or saturation with respect to the wristband. It’s similar to how too many alarms cause issues—less is more.
Third, we have such wonderful technology that we simply don’t use to our advantage: Wristbands are often generated through computer programs that do not link or communicate with the EHR and function in a silo.
Q: What common mistakes do hospitals make in verifying patient IDs?
Mount-Campbell: Bar coding systems have helped to reduce errors for things like medication delivery. These bar codes are typically on the patient wristband. You can imagine if someone is wearing the wrong wristband and how the computer doesn’t know that, and how it could lead to the delivery of the wrong medication.
Often, for privacy reasons (which I do not understand), facilities do not put patient photos on their wristband. Photos have been shown to help prevent patient ID mistakes. You may not remember a patient name, but it’s easy to match a face.
A lot of facilities use wristbands to communicate information about the patient, such as allergies, fall risk, choke risk, restricted extremity, and DNR (do not resuscitate). I view this as a mistake, especially when they only use colors and no words to communicate. Back when the yellow Livestrong™ bracelets were popular (early 2000s), patients wearing the bracelets died because numerous healthcare facilities used yellow wristbands to indicate a DNR patient.
Pennsylvania and Arizona produced guidelines, which are now used internationally, that suggest standard colors (DNR is now purple) and [state] that admitted patients need to remove all personal items they wear around their wrist.
Q: What are some of the best practices for patient identification? Best resources available?
Mount-Campbell: The best practices happen at facilities where someone owns the process—and where nurses, physicians, and techs alike verify patient identity when it’s convenient. By convenient, I mean during bedside clinician handovers for nurses, during rounds for physicians, or when collecting vital signs for techs.
Our best resource has been and will always be people.
Q: What should a hospital or health system do if it has two patients with the same name and date of birth to prevent a mix-up?
Mount-Campbell: Having photos on patient wristbands helps. Alternatively, using a medical record number matching system can help, as they are unique. The problem with that, though, is there is no patient who is going to know what [their medical record number] is or have it memorized.
Q: What are your thoughts on using patient photos as a way to ensure identification?
Mount-Campbell: I think it’s 100% a must (seeing how I mentioned it in previous questions). Upon admission, a photo should be taken of the patient, so it is current, but also should be matched with old photos in the system for error prevention.
I know of situations where the wrong photos got into the system by mistake, and the EHR had no option to remove or delete old photos. It couldn’t even remove mistake photos (as unbelievable as that sounds). Their solution was to stop using photos, which in my opinion is a mistake.
Q: Do you think the problem of patient mix-ups can be solved by technology alone (wristbands, EMR), or is it more a matter of better training for medical staff?
Mount-Campbell: Well-designed technology or a well-designed system can most definitely make this practically a non-issue. Well-designed technology should be intuitive and require no training.
The public at large doesn’t get training on how to use a smartphone. Why is it that in the healthcare industry, providers are OK with paying for overpriced technology that also requires hours and hours of training? It does not need to be this way. Just because healthcare is complex doesn’t mean the software tools provided need to be.
Q: What should the protocol be when a mix-up is discovered? For example, Patient A has been labeled Patient B for a week. Do you inform the patient? Administration?
Mount-Campbell: Just Culture! You must inform everyone. If you hide it or cover it up instead of learning from the mistake, you are doomed to repeat it and nothing is learned.
No punitive action should be taken. The incident should be investigated so we can learn from it and prevent future events.
Q: If you were trying to convince a hospital to make patient identification a higher priority, what would you say?
Mount-Campbell: I would try to put them in the shoes of a patient who experiences a mix-up. I would talk about the cost associated with a mistake and potential lawsuits.
Q: Have you ever experienced a close call or accident involving a patient mix-up? How was it discovered?
Mount-Campbell: I do research, patient safety, and system improvement, so my patient interaction is never clinical. But I have a secondhand story.
This was at a facility where the EHR would present a photo of a patient when you opened the chart. The doctor was having a normal clinical interaction, opened the chart, and was aghast to see the patient’s EHR photo was of a black man but the patient in the chair was a white man.
The doctor explained his reaction and showed the patient his chart. The patient laughed and laughed. He then told the doctor he knew who was in the photo—it was the guy in front of him when they took the photos way back when. It turns out the chart was correct, just the photo was wrong.
The best part is even though the photo was wrong, it alerted the doctor that there might be an issue. It was quickly rectified and no patients were harmed. This just goes to show the value of a photo. Even a clearly wrong photo is more valuable than a wristband with a name and bar code because it forces the doctor to scrutinize the patient’s identification.
The administration learned of this event, but it made the mistake of turning off the photos in the EHR. I cannot express enough how big of a mistake I believe this was. I guarantee more patients were associated with ID errors going forward.
Q: Anything else you’d like to add?
Mount-Campbell: With the ever-decreasing cost of radio-frequency identification (RFID) technology, potential benefits to patient wristbands and patient ID could be tremendous.
The opinions expressed by Dr. Mount-Campbell are not necessarily the opinions of VA Pittsburgh Healthcare System or the Veterans Health Administration.