By Erin Benson, Director Market Planning – LexisNexis Risk Solutions
Imagine two patients with the same last name, admitted for separate ailments at the same hospital. One is mistakenly treated with a medication intended for the other patient—and has a serious reaction to the drug. Patient mix-ups are all-too-frequent occurrences at many hospitals across the U.S., leading to redundant tests, wrong diagnoses, incorrect treatment services and unnecessary hospitalizations – while increasing costs.
The ECRI Institute Patient Safety Organization reviewed 7,600 wrong-patient events over a 32-month timeframe – voluntarily reported by 181 health organizations. Of these mix-ups, most were caught early, but 9 percent resulted in death or harm to the patient.
A similar study from the RAND Corporation found that health providers duplicate patient records on average 8 percent of the time. Patient misidentification costs hospitals an average of $17.4 million each year in denied claims. Furthermore, physicians treating the whole patient along a care continuum require more than a snapshot of a visit or sparsely detailed record. They need access to a person’s full medical history including diagnoses, medical images, lab results, procedures, family background and medication history. To make on-the-spot decisions for accurate diagnoses and sensible treatment plans, care providers must know the right information about the right patient. Outcomes depend on it.
What Goes Wrong: Intake Challenges
Incorrect patient identification often begins as soon as a patient is admitted and entered into the system. Often, an employee who is inputting the data makes a clerical mistake, such as mistyping the Social Security number, birth date or name. Many times, healthcare providers use disparate systems and naming practices to identify the patient. For example, there may be discrepancies in how to input hyphens in names or suffixes such as “Sr.” or “Jr.” Care providers often handle middle names differently: include, exclude or put in a middle initial.
When healthcare staff cannot locate a patient’s record in their system, the next seemingly logical step is to create a new record and enter the patient information. Unfortunately, this duplicate record workaround causes the spreading of patient history and data over multiple records that represent, in fact, the same patient. Then, each record holds an incomplete snapshot of the patient’s health and procedures. In other instances, marital status updates or address changes may lead to confusion. A patient may be lost in the system or unreachable to receive important medical notifications.
What Goes Wrong: Systemic Weaknesses
Looking at the big picture of healthcare provision, it can be difficult for an organization to keep track of its patients. Insurance companies, providers and patients themselves often identify the same person in a variety of ways. While electronic medical records have presented an opportunity for technology to improve care and information-sharing, lack of interoperability has added another obstacle to linking health data and correctly identifying patients.
As disparate systems attempt to “communicate” and integrate, there are more opportunities for confusion and “quick fixes” in the moment that only complicate matters in the long run. Every laboratory test, medical imaging scan, specialist consult or hospital stay becomes an additional point where mistakes can be introduced into a patient’s medical records.
Having multiple electronic files for many patients—some duplicate patients—has resulted in substantial overhead for healthcare providers. On average, clinicians waste 28.2 minutes per shift searching for correct medical records for patients. Not only does this hinder productivity, it also disrupts the workflow and coordination of patient care.
Face-to-face missteps during hands-on care provision are also common; nurses or physicians may try to cross-check a patient by name or birthdate, but challenges still exist in ensuring the right patient is receiving the right care.
For example, the Patient Safety Network highlighted wrong patient errors at University of California San Francisco Medical Center. The researchers examined the roster for only two medical floors. They found two patients with the same last name, Chan, and three pairs of patients with similar sounding surnames. To better understand patient mix-ups, they analyzed the hospital’s medical service to see how often there were identical last names. In a three-month period, inpatient services had two patients with the same last name on 28 percent of the days.
Clearly last names, on their own, are not enough to identify patients—especially when same-named patients share the same room – an occurrence that happens more often than you’d think. Without another obvious patient identifier, errors are imminent.
Improving Outcomes: A Solution
Mismatches jeopardize patient safety and care outcomes. A national system that assigned a unique patient identifier to each patient would streamline the identification process, reduce errors and cut costs. The ideal system would join medical records from disparate providers and care settings linking all relevant information.
A main, referential database would serve as a safe, accurate and continually updated repository that improved matching technology of patient records. The aggregated data would give patients, hospitals, insurers, physician practices and pharmacies the confidence of seeing the whole picture of the whole patient: the correct patient.
Some government-run national health systems abroad have turned to unique or universal identifiers to solve many of their medical errors challenges. In Great Britain, every patient gets a National Health Service Number. Both Australia and Singapore have implemented their own health ID programs. The U.S., where the incidence of medical identity theft continues to rise, could also benefit from the safety and protection of an identifier system.
About 86 percent of providers have witnessed or have known of a medical error due to misidentification. Are you one of them? For the safety of patients, there needs to be a plan in place to prevent such errors from occurring again.
About The Author
Erin Benson serves LexisNexis Health Care as Director, Market Planning. Her focus is on the development and execution of strategic planning for Identity Management and Socioeconomic Determinants of Health solutions. Prior to joining LexisNexis, Ms. Benson worked at Deloitte Consulting. She holds a Bachelor’s and Master’s degree in Human and Organizational Development from Vanderbilt University and an MBA in Strategy and Management from Duke University, The Fuqua School of Business.