Addressing Mistaken Identity in Healthcare Settings

What happens when two different patients have the same name? What happens when a single patient has multiple patient IDs? At risk is far more than record-keeping blunders: patient safety may be compromised, and MLMIC wants to alert policyholders to the need for protocols that can prevent such errors.

Consider the first example in which two patients share a name. The Boston Globe reported on this issue in Massachusetts with the recent article, “14 instances of right procedure, wrong patient,” describing scenarios in which patients were delivered someone else’s test results and subsequently underwent unnecessary procedures, such as endoscopies, biopsies and in one case kidney removal. According to the article, “Federal regulators [are requiring] the hospital to correct shortcomings in its identification practices or risk losing its contract to treat Medicare patients.” The Joint Commission statistics cited by The Boston Globe reveal that “procedures done on the wrong patient or the wrong body part, or instances where the wrong procedure was done, happen 40 to 60 times a week in hospitals.”

In the second example – when one patient has numerous patient IDs – the risk is that a provider sees incomplete information when electronic systems fail to properly match all the patient’s records. Why wouldn’t the system be able to retrieve all records for a single individual reliably? Here’s how it happens, according to a recent piece in Advisen Healthcare Front Page News: “John Smith’s record at Hospital A might have his home phone number and his given name. His record at Hospital B might have his cell phone number and list him as Jack Smith, which might be his preferred nickname. Both records are for the same person, but they don’t match. [In addition] common automated matching systems also won’t recognize duplicate records are created when a patient changes addresses, or gets married and changes her last name.” Due to the potential for data breaches, social security numbers are no longer an option for a “unique identifier,” per The Medicare Access and CHIP Reauthorization Act of 2015, says Advisen.

MLMIC agrees with Advisen as it concludes, “Clinicians know providing the highest level of care quality requires a complete picture of a patient’s health and medical history. Treating people with the highest level of integrity requires deep commitment to accuracy.” To ensure patient safety, healthcare providers must put in place procedures and policies – as well as digital solutions, when appropriate – that confirm patient identity with the highest level of certainty.