Patient misidentification is far too prevalent in our healthcare system, a silent crisis that can maim or kill. It's preventable, another treatable condition that can be tended to with the right amount of attention from doctors and nursing staff.
According to a 2016 National Patient Misidentification Report of nurses, physicians and practitioners within IT, the frequency of such troubling events was surveyed in an effort to determine some of the root causes of a devastating problem within the medical field. Misidentification at registration, such as "incorrect armband placement" was determined to be the top leading cause of identification errors, ranking to account for 63% of them within the survey. Pressure to work under time-sensitive conditions when treating patients, especially in a busy facility, fell closely behind that statistic to account for 60% of the misidentifications reported.
What happens to the patients caught in this identity crisis? The impact of these errors can't be measured in percentages when emotional stress, financial hardship, and possible trauma are involved. No one should leave a medical facility in more pain than they were in to begin with. As it stands, 7-10% of patients are misidentified during record searches alone, leaving them in the hands of unpredictable care. To make things more worrisome, the same survey reported that 86% of respondents had known of a medical error due to wrong-patient events.
Why do doctors misidentify patients?
"Wrong patient events" are preventable cases of mistaken patient identity. While not done on purpose, this error can lead to catastrophic consequences for those who have to suffer it. At the start of every visit, a patient's identity should be verified-their name, birthdate, and last four digits of their phone number are commonly used identifiers. Even with these, a patient's identity cannot be assumed to be 100% verified. That's why it's so critical that medical providers take all appropriate steps to verify the patient's identity.
Patients can be anxious, or suffering from shock, delirium, or a mental illness that impairs their cognitive ability to successfully identify themselves. Such a case happened to a 28 year old patient awaiting ambulatory surgery; the nurse verbally confirmed her name, and even the type of surgery she was scheduled to have - according to the nurse's chart, which turned out to be erroneous. In fact, the error wasn't caught until she was on the operating room table where an anesthetist checked her wristband and immediately brought attention to the mistake. Despite answering positively to all questions directed towards her, anxiety had rendered this patient unable to be fully mentally present. This near-catastrophic error could have been prevented if the nurse had simply checked the patient's wristband.
Nurses aren't the only ones at risk to succumbing to a dangerous lack of attention to detail.
The ECRI (Emergency Care Research Institute) Institute has released reports on patient misidentification, including chilling statistics and the conclusion that "...anyone on the patient's healthcare team can make an identification error, including physicians, nurses, lab technicians, pharmacists, and transporters." The Patient Safety Organization partnered in this study in the attempts to pinpoint where exactly these errors began.
- 3% of wrong patient events took place during actual patient encounters
- 6% took place during the intake process
- Over half of wrong-patient events involved diagnostic procedures or treatment associated with them
- Two patient deaths involved were associated with documentation failures, including one that gave clearance for surgery on the wrong patient.
"The risk for patient errors is ever-present," says the ECRI's executive director. It's so present that the numbers seem almost too low. Under-reporting patient errors and not disclosing them to patients is still an issue for the world of healthcare, which means that we may not have a clear idea of how many more cases there really are. Biometric solutions have been proposed to be a solution to consider, such as Imprivata's PatientSecure system that utilizes palm vein recognition to identify patients, but their implementation has no guaranteed launch date.
What happens to the patient?
When the right procedure is performed on the wrong patient, the malady that ensues has effects on more than one party. Depending on the procedure performed, consequences can range from mislabeled blood samples to injecting IV contrast into a patient with an allergy.
In one of the more severe cases, a surgeon removed a kidney from the wrong patient due to an instance in which two patients had the same name. A CT scan had showed a tumor on the left kidney, which was removed and discovered to be tumor-free upon examination by a pathologist.
In another case, a non-English speaking patient was confused with another who bore the same name and similar birth date. Results from his CT scan that indicated cancer were sent to the second patient's doctor, who only caught the mistake as he was about to go through a second biopsy.
35 percent of denied hospital claims involve inaccurate patient identification, which puts the patient at risk of having to pay for some of the treatment that they shouldn't have undergone in the first place. Depending on the event, a physical recovery period may be needed, which would result in lost wages. In too many cases, an entirely preventable medical error leaves patients with permanent scars and other irreversible damage.
Our law firm holds negligent medical providers accountable.
Medical malpractice needs to be handled by someone with experience and compassion. The Jonathan C. Reiter Law Firm, PLLC is dedicated to an individualized approach to cases where clients are victims of negligence and preventable events. They may feel silenced, but patients have a voice they may not realize still exists. If you or a loved one has been misidentified and subsequently injured, contact our firm immediately for a free case evaluation.