The Joint Commission Issues Patient Identification Advisory

Patient identification occurs every time a health care professional has a conversation with a patient and any time information about a patient is recorded or assessed. Because this process is universal, it is fraught with risk for wrong-patient errors that can lead to delays in treatment or providing treatment to the wrong patient. 

Preventing wrong patient errors is the focus of a new advisory from The Joint Commission. Quick Safety, Issue 45: People, processes, health IT and accurate patient identification provides recommendations for health care professionals to consider when relying on human and/or technology factors to identify a patient. Errors caused by both relate to distractions, time constraints, fatigue, display issues, refresh times, down times, communication issues, use of aliases, nondistinct temporary names and staff workarounds. 

HIT can raise even further considerations as common problems include entering information into the wrong patient record, untangling (ie, separating) co-mingled patient information, mistakenly creating duplicate charts, and assigning a test to the wrong patient, according to the advisory. These errors can lead to incorrectly routed information, wrong results, delayed or inappropriate care, or misdiagnosis. 

"Technology alone cannot ensure accurate patient identification," says Gerard M. Castro, PhD, MPH, project director of Patient Safety Initiatives for The Joint Commission. "We must consider not only the technology, but also the people involved and their processes. It is essential for health care professionals to receive adequate training and conduct reliable procedures. Accurate patient identification involves shared responsibility and involvement of all stakeholders."

Recommended safety actions that support accurate patient identification are outlined in the advisory, including the following:

• Utilizing an active confirmation process to help match the patient and documentation. 
• Using a standardized process for patient identification and capturing patient information no matter where registration occurs. 
• Ensuring information required to accurately identify the patient is clearly displayed on  electronic displays, wristband, and printouts. 
• Implementing monitoring systems to readily detect identification errors, such as regular inspection for patient identification errors and potential duplicate patient records. 
• Including high-specificity alerts and notifications to facilitate proper identification, such as warning users when they attempt to create a record for a new patient (or look up a patient) whose first and last names are the same as those of another patient. 

— Source: The Joint Commission