Patient Misidentification in Oncology Care

Abstract

Patients with cancer are at risk for patient misidentification, or "wrong patient" incidents. Patient misidentification can result in medication and transfusion errors, unnecessary testing or procedures, and, in some cases, death. Patients may be misidentified when nurses mispronounce their names, refer to them by their first or last names only, are complacent and fail to check armbands, or encounter language or communication barriers. Errors caused by patient misidentification can be prevented when healthcare providers consistently use two unique patient identifiers (other than the patient's room, examination, or chair number) to verify identities.

Evaluation of the risk of misidentification of women in a public maternity hospital

“…The Health Department of the United Kingdom recommends that this record is unique and used by all health services, but privacy and safety issues, such as theft of personal information, and flaws in the combination of patients in these electronic systems indicate the need to resort to other identifiers. Clinical data, name, surname, date of birth, social security number, address, phone number, postal code and gender can be combined to allow the correct patient identification and prevent duplication of medical records or multiple recording of the same user, as has been demonstrated by several authors (18)(19)(20)(21)(22)(23) . Similar or identical names can originate mistakes when computed systems require identifiers -first and last names and numerical registries -to find patient information in health services (2,24) .…”

“…Other situations that expose healthcare professionals to the risk of misidentification include high number of patients, incomplete pronunciation and spelling and sound similarity, among others (2,8,19,21,27) . A study estimated that the use of identification wristbands and verbal checking of the patient's name by professionals have 80% of effectiveness for correct identification (28) .…”

Human factors engineering approaches to patient identification armband design

“…Patient misidentification and associated preventable patient harm occurs daily nationwide with potentially fatal consequences (Gray et al, 2006;Schulmeister, 2008). Errors in the identification process can occur in a myriad of care encounters, such as blood transfusion, medication administration and specimen collection (Mannos, 2003;Pagliara and Rubella, 2006;Valenstein et al, 2006).…”

Patient identification and tube labelling – a call for harmonisation

“…Patient identification is a key point in patient laboratory processing [16,17]. Proper patient identification relies on at least two independent identifiers [18,19].…”