Cases of Mistaken Patient Identity

Cases of Mistaken Patient Identity

Introduction

Patient identification is one type of medical error that frequently occurs during the delivery of health care. The term "medical error" refers to any instance in which a healthcare provider causes harm to a patient by acting in a way that deviates from accepted practice, fails to produce the desired results, or follows the wrong course of action (Makary & Daniel, 2020). The 1999 IOM (Institute of Medicine) report titled "To Err is Human" highlighted the prevalence of medical mistakes in the United States. Medical mistakes, such as those connected to incorrect patient identification, were described in depth in the paper. As everyone in the healthcare field can attest, misunderstandings over a patient's identity are unfortunately commonplace. This failure to precisely identify patients translates into transfusion errors, prescription errors, inappropriate treatments for patients, errors in patient testing, and infants being sent to the wrong families virtually every day in the United States of America. Patients' safety is at risk due to widespread problems with patient identification in American hospitals. The high volume of people seeking medical attention and the complexity of the healthcare delivery system both contribute to the frequent occurrence of patient identification mistakes that plague the healthcare industry. Surgery is frequently associated with identification errors. However, they aren't limited to just inpatient or auxiliary or long-term or even outpatient settings; they can occur anywhere healthcare is provided. There is still a problem with identifying mistakes in the healthcare business today, even though technology has been implemented and improved in the American healthcare system to try to remove them. Trust, reputation, and finances of patients are all at stake here. The problem of patient identification must be solved if secure healthcare is to be developed. The purpose of this study is to have a theoretical discussion about how to solve the problem of patient identification in healthcare.

Definition of the Issue

The numbers reveal that wrong is a major problem in the USA. Researchers at the Emergency Care Research Institute (ECRI) reported that over 7,000 cases of incorrect patient identification occurred in 2.5 years (De Rezende et al., 2019). Some instances of identification are not even documented. This shows how the problem of identification inaccuracy persists, which is a threat to the delivery of safe and effective medical care. Thus, addressing this issue is critical to fostering a more secure healthcare system.

Analysis of the Literature

The problem of patient identification has been documented in several studies. A multi-institutional look at hospital ID bracelets at 712 American healthcare facilities is one example. Out of a total of 2,463,727 identifying wristbands, 2.7% (67,289) were found to have inaccuracies (World Health Organization, 2018). The lack of identifying bracelets was the cause of 49.5% of these mistakes. This study was expanded to include another 204 institutions, and researchers found that 5.7% of the wristbands analyzed (or 28,800 out of a total of 451,436) contained at least one error in patient identification. Between 2013 and 2016, the ECRI Institute examined 180 healthcare facilities from across the globe. The purpose of the research was to learn more about the frequency and causes of patient identification errors at these facilities. From 2014 to 2017, there were 409 recorded sentinel occurrences, or 12.3 percent of the 3326 total incidents studied. Seventy-two percent of the incidents occurred during patient interactions, 36.5 percent during diagnostic procedures, and 22 percent during treatment, as stated in a report by the ECRI institute. In addition, 10% were caused by insufficient paperwork.

According to the institute's findings, had these cases not been detected in time, they could have had devastating consequences for the patients. Two of the patients whose identities were incorrectly reported subsequently passed away. The Ponemon Institute found that in 2015, identity theft was a major contributor to patient identification mistakes in the United States healthcare system. In the United States, healthcare identity theft is a growing problem. This analysis estimates that 2.32 million adults in the United States were victims of medical identity theft in 2014. Unauthorized identity theft accounted for 35% of all cases. Despite this, 25% of these adults admitted to having permitted someone else to use their identity, usually due to a medical emergency, financial hardship, or lack of insurance. Researchers Mancilla and Moczygemba set out to examine the problem of medical identity theft in a study (Mancilla & Moczygemba, 2017). They found that identity theft in healthcare is common because staff members aren't always on the lookout for unusual paperwork. This could be due to a lack of training or a lack of time to carefully examine each document. Patient identification errors and near misses can now be better tracked and detected because of the widespread use of barcoding systems, electronic health records, and automated order entry systems in the healthcare sector. Insights on the role that technology plays in patient identification mistakes have also emerged as a result of its widespread adoption. Technology, by itself, is not capable of resolving this intricate problem. For instance, research indicates that between 49% and 96% of signals received by providers during order input are disregarded.

Case Theory Exposition

Several hospitals in the United States have had high rates of patient identification errors. Some patients are fortunate enough to have their misidentifications caught and corrected before anything horrible happens to them, but in other circumstances, misidentifications lead to difficult situations or even death. Case in point: Indiana native Margaret A. McGiffen, underwent necessary surgery in 2012 but survived because of a mismatch between her medical records and the patient's name. When she asked for some sleep aid per her doctor's orders, the nurse said she couldn't find anything. Upon noticing that her wristband identified her as Margaret L. McGiffen, a person who takes 19 medicines daily, she suspected that there had been an error.

Patient identification errors are unfortunately common, and this is only one example. While healthcare providers are aware of the benefits of asking patients for their dates of birth, and names, and checking their identification wristbands, mistakes in patient identification still occur for a variety of complex reasons. Time constraints in healthcare settings, inaccurate patient data recorded on identification bracelets, scarce resources, and inadequate staff training are all possible causes. The patients well-being and safety are put at risk by these mistakes. The Institute of Medicine (IOM) in the United States estimates that the cost of medical mistakes is shockingly high. As a result of these mistakes, approximately 98,000 Americans lose their lives per year, which is more than the number of deaths now attributed to gun homicides as reported by the FB (Lippi et al., 2017). Patients could be harmed directly, wrong diagnoses could be made, the wrong medications could be given to patients, procedures could be performed on the wrong people, patients could have their procedures repeated without their knowledge, and babies could be sent home with the wrong families, and everyone involved would be under undue stress due to the lack of time. Medical systems, which are meant to improve patients' health, actually end up hurting them instead due to human mistakes. Health care quality and patient safety are jeopardized when incorrect patient identification is used.

Discussion

According to the findings of this literature analysis, patient identification errors are a major problem in healthcare in the United States, posing a threat to both patient safety and the quality of treatment they get. Previous research that looked at these blunders in a subset of hospitals found that a certain number of them occurred, leading to either unfavorable consequences or close calls (ECRI Institute, 2018). This suggests that the issue is not unique to a small subset of hospitals, but instead impacts the vast majority of hospitals across the country. There is a pressing need for actions to curb the prevalence of identification mistakes in the United States healthcare system. A multidisciplinary team, including the patients themselves, should carry out the interventions. Many hospitals have implemented a variety of tactics and activities to prevent such events from happening. The usage of identification wristbands and the development of new technologies to improve patient safety are two typical practices at many hospitals (ECRI Institute, 2018). However, the issue of incorrect patient identification persists despite the implementation of these solutions. The identification bands add to the issue, as shown by the numerous research that has examined the relationship between wristband use and patient identification mistakes. The World Health Organization found that out of all the identification bands they checked, just 2.7% contained mistakes in the corresponding names or other personal information. Inadequate identification bands were the cause of nearly half of these mistakes. Identification mistakes can occur because of incorrect information on the wristbands. ID bracelets play an important part in helping hospitals reduce medical mistakes caused by misidentification, but they can potentially add to the problem if they contain inaccurate data. Patient identity theft, which is another contributor to patient identification problems in the healthcare industry, was not addressed by identifying bracelets, according to a report by the Ponemon Institute (ECRI Institute, 2018). A medical emergency, inability to pay and lack of insurance are just a few of the causes of identity theft in the healthcare industry. Wristbands alone won't fix this problem; instead, we need innovative approaches to patient identification in the healthcare system. Bar-coding systems, electronic health records, and computerized order entry systems are just some of the examples of cutting-edge technology being used by hospitals to better monitor and report patient identification errors and near-misses to eradicate them. Yet, the problem of incorrect patient identification has not been resolved using this method. An ongoing difficulty in preventing patient identification mistakes is the insufficient training of healthcare personnel to use these tools. Studies show that between 49% and 96% of notifications sent to providers during order input are never acted upon (ECRI Institute, 2020). This shows that the problem cannot be fixed by technological means alone. To solve this problem, multiple approaches will have to be integrated. Patient identification errors can be significantly reduced by adopting a multidisciplinary approach to quality improvement.

Synopsis of the Case

As the first step in providing care, patient identification is essential and can save lives. If used properly, patient identification can aid in avoiding medical mistakes and keeping patients safe. Patient identification has been a problem in the healthcare sector in the United States, with recorded instances of identity errors having a significant impact on the provision of healthcare. The use of identification wristbands and cutting-edge technology are just two examples of the many methods hospitals have adopted to eradicate this common source of inaccuracy (ECRI Institute, 2018). Because these methods have not proven effective in preventing patient identification errors, this problem remains a serious one in the healthcare profession today. Because this is a complicated and multidimensional issue, it has been demonstrated that no single solution will work. Therefore, to successfully lessen patient identification errors, a multidisciplinary approach to quality improvement is essential. More work in the healthcare sector is needed to eliminate this common root cause of avoidable mistakes.

Proposed solution

Medical centers can close the identification-related voids in service by implementing a few different measures. The first thing we need to do is examine their id procedures to figure out what's going wrong. The Root Cause Analysis (RCA) method can be used to get to the bottom of things by learning from the organization's previous missteps. Facilities can benefit from identifying the causes of noncompliance to better comprehend the aspects that contribute to the problem and implement lasting solutions (ECRI Institute, 2018). Safeguarding is an alternative approach to solving the problem. With so many people seeking medical attention, it is not enough to rely merely on date of birth and name to verify patients' identities. In light of this fact, hospitals and other healthcare facilities can reduce the likelihood of patient identification errors by adopting more sophisticated identifying wristbands. Some ideas include having patients wear identification bracelets with photos and barcodes that may be scanned before beginning any additional medical procedure. Businesses should think about using biometric authentication methods like fingerprint, retina, and print scans.

Additionally, healthcare facilities should provide their employees and patients with more agency. Before any kind of operation, it's important to get the patients input. Patients can participate, for instance, by being handed consent forms to read and sign before a surgical procedure, paying close attention to the location of the incision and the specifics of the procedure described therein. These measures can aid in preventing wrong-patient operations and wrong-site surgery (De Rezende et al., 2019). The same holds for the personnel and patients: the more they know, the more they can do. Members of staff should feel safe raising issues about the accuracy of identification procedures (De Rezende et al., 2019). The World Health Organization recommends a few different methods to reduce the occurrence of patient identification mistakes. Among these recommendations are the utilization of multiple IDs for authenticating one's identity, the uniformity of identifying methods within a healthcare system, and the incorporation of cutting-edge technical assets.

Research Method for Analyzing the Solution and Assessing the Method

The efficiency of the countermeasures will be measured using Root Cause Analysis (RCA). This is a methodical approach to investigating accidents, to pinpoint the causes of increased error rates (Okes, 2019). Errors at the point when a complex system interacts with humans, as well as those that are concealed within the system itself, can be uncovered using root cause analysis. By employing this method, a group of experts can examine the chain of events leading up to an error to determine what went wrong and why. The ultimate objective is to address and mitigate the root causes of these mistakes so that they don't happen again in the future. This instrument will help evaluate the solutions by determining if they successfully reduced the underlying issue. A dedicated group can track how the tool is used and the results it produces to determine its efficacy.

Conclusion

Unfortunately, incorrect patient identification is a widespread problem in the modern healthcare system. Transfusion errors, medication problems, inappropriate patient treatments, incorrect test results, and infants being sent to the wrong families are just some of the many dire consequences of these lapses in care. Health care quality and patient safety are jeopardized when incorrect patient identification is used. Implementing biometric identification methods like print scans, retina, or fingerprints, educating staff and patients, employing two or more identifiers for identity verification, and standardizing the identification processes across a health institution can all help to reduce these types of mistakes. The Root Cause Analysis method can be used to assess the effectiveness of these interventions (RCA). As a result, the healthcare sector must make more efforts to mitigate this root cause of avoidable medical mistakes. As a means of guaranteeing both service quality and patient safety, healthcare facilities everywhere should make accurate patient identification their top priority.

References

De Rezende, H. A., Melleiro, M. M., & Shimoda, G. T. (2019). Interventions to reduce patient identification errors in the hospital setting: a systematic review protocol. JBI database of systematic reviews and implementation reports, 17(1), 37-42.

Lippi, G., Mattiuzzi, C., Bovo, C., & Favaloro, E. J. (2017). Managing the patient identification crisis in healthcare and laboratory medicine. Clinical biochemistry, 50(10-11), 562-567.

Makary, M. A., & Daniel, M. (2020). Medical erroris the third leading cause of death in the US. BMJ, 353, i2139.

Mancilla, D., & Moczygemba, J. (2017). Exploring medical identity theft. Perspectives in health information management/AHIMA, American Health Information Management Association, 6(Fall).

Okes, D. (2019). Root cause analysis: The core of problem-solving and corrective action. ASQ Quality Press.

Patient Identification, World Health Organization, (2018). Pdf.

"Patient Identification Errors." ECRI Institute, 2018. Web.