Blake R. Griese
As hospital healthcare costs continue to rise, so, too, do patients' expectations of enhanced care, shorter stays and improved outcomes. Consequently, hospitals are continually searching for ways to develop and implement patient safety initiatives that facilitate both increased quality of care and decreased costs incurred by both patients and hospitals.
Charise R. Frazier
It was the Institute of Medicine's 1999 report, To Err is Human, that really launched the patient safety movement.1 Although physicians, hospitals and their administrators continue efforts to identify the best methods and programs to improve patient outcomes, there is little question that patient safety initiatives are essential to ensure their success.
The total national healthcare cost of preventable medical errors resulting in patient injury is between $8.5 billion and $14.5 billion.2 By implementing patient safety initiatives, including efforts to ensure accurate patient identification, these extraordinary costs can be decreased, medical errors can be reduced and overall patient outcomes and experiences enhanced.
In many instances, medical errors are a direct result of incorrectly identifying patients in hospitals. In the summer of 2010, a Maryland hospital reminded healthcare facilities around the country what can happen when a breakdown in a hospital's patient identification protocol occurs.
In that case, a local retired sheriff involved in a motor vehicle accident was flown to the hospital. A doctor at the hospital explained to the sheriff that he suffered minor head injuries and as a result needed to stay at the hospital for 24 hours for observation and evaluation.
The next day when the sheriff awoke, the nursing staff explained that he was scheduled for surgery to have a cancerous lump removed. The sheriff explained that he was never diagnosed with cancer and he became noticeably upset. Soon after, the sheriff's wife discovered the hospital had placed the wrong identification bracelet on him. The sheriff, quite upset, ripped out his I.V. and started to leave. The nurse called security, who arrived shortly thereafter and apprehended the sheriff before he could leave.
The sheriff later claimed that he was assaulted by security and he filed a lawsuit against the hospital and its security contractor for approximately $13 million. This incident resulted directly from the patient being misidentified upon entering the hospital.
Even if patients are correctly identified upon admission, they can be misidentified during the hospital stay if appropriate patient safety initiatives are not implemented. In a recent case, a registered nurse walked a patient from surgical daycare to the operating suite. The nurse read the name on the chart nearest to the patient, and asked the patient if that was his name. The patient answered in the affirmative, but unbeknownst to the nurse, the patient was experiencing extreme anxiety and comprehended very little of what the nurse was asking. When the nurse anesthetist entered the operating suite to begin the procedure, she checked the patient's wristband and discovered the wrong patient had been brought to the operating room.
In this instance, the error occurred because the first nurse failed to confirm that the name on the chart matched the patient's wristband identification, and failed to use open-ended questions (e.g., "What is your name?" versus, "Is your name John Smith?") when verifying the patient's identity.
Regulatory & Accreditation Requirements
In addition to the obviously compelling patient care advantages of heightened efforts to ensure accurate patient identification, initiatives related to proper identification of patients are required by various accrediting agencies. For example, the Joint Commission requires that hospitals use at least two patient identifiers (such as patient name, an assigned identification number, telephone number or other person-specific identifier) when administering medications or blood, collecting blood samples or test specimens and when providing treatments or procedures.3
Similarly, the Healthcare Facilities Accreditation Program (HFAP) requires organizations to create a healthcare culture of safety, which includes assurance that patient safety issues are appropriately addressed, in order to receive accreditation.4 State hospital licensure rules generally require hospitals to implement policies and procedures that include a reliable method of patient identification. The Medicare Conditions of Participation require hospitals to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program that includes accurately identifying patients and the patient's right to receive care in a safe setting.5
Therefore, hospitals that fail to implement proper safety initiatives run the risk of losing accreditation from accrediting organizations such as the Joint Commission and HFAP. Additionally, failure to develop and implement proper initiatives could result in hospitals jeopardizing their state licensure or losing privileges to participate in Medicare and Medicaid programs.
Also, insufficient and ineffective safety initiatives may result in adverse events and, under certain state laws, could trigger a mandatory reporting obligation for hospitals. These events may expose hospitals to significant legal liability through civil lawsuits.
Additionally, the hospital may be liable to the patient under a theory of negligence if the patient can demonstrate that the hospital has breached the standard of care by not having appropriate safety initiatives in place. Furthermore, a hospital may be responsible for not only actual damages but punitive damages as well.
Strategies for Improving Patient Identification
There are a number of strategies a hospital can adopt to improve patient identification. The use of two identifiers is one of the least expensive and most common methods. Such identifiers should not include the individual's room number (which may change during the hospital stay), or any other proprietary information (such as Social Security number or Medicare/Medicaid information). Some hospitals are implementing bar-coding systems that verify patient identity at the point of care. Other hospitals are reducing hours staff are allowed to work, as fatigue increases the risk for patient misidentification.
Although advocates of more expensive solutions such as bar-coding assert that the expense of such systems is more than offset by cost savings recognized from avoiding expensive medical errors, it is important that hospitals not overlook relatively simple and inexpensive measures. For example, rigorous adherence to "time out" processes prior to procedures can avert many serious safety events, including those involving misidentification of patients.
The seemingly simple process of accurate patient identification is one of many patient safety initiatives that play a key role in ensuring that quality care is provided to patients. Therefore, it is essential for hospitals to have the appropriate safeguards in place to prevent patient misidentification, as effects of even one instance can be devastating to both the patient and the facility.
Facilities run the risk of not only losing accreditation, but also their state license or Medicare and Medicaid status, as well as substantial fiscal loss. More importantly, failing to take proper safety initiatives may put patients at risk of immeasurable harm, as severe injury or even death may result.
1. Macklis, R. (2001). Successful patient safety initiatives: Driven from within, Group Practice Journal. Retrieved from the World Wide Web: http://www.positivedeviance.org/pdf/publicationmrsa/Group_practice_journal_patient_safety.pdf
2. Guadagnino, C. (2000). Impacts of error reduction initiatives. Physician News Digest. Retrieved from the World Wide Web: http://www.physician news.com/cover/200.html
3. Joint Commission (2011). National patient safety goals, NPSG 01.01.01.
4. Healthcare Facilities Accreditation Program. (2008). Accreditation requirements for healthcare facilities, 12.00.22.
5. Department of Health and Human Services. Quality Assessment and Performance Improvement (42 CFR 482.21). Washington, DC: Author.
Blake R. Griese is an associate at the legal firm of Hall, Render, Killian, Heath & Lyman, P.C., which provides healthcare organizations with legal representation; Charise R. Frazier is a shareholder at Hall, Render, Killian, Heath & Lyman, P.C.