Registration-Associated Patient Misidentification in an Academic Medical Center: Causes and Corrections

Matching identifiers in electronic health records: implications for duplicate records and patient safety

“…The first approach is prevention, where institutions try to keep duplicate records from occurring. Prevention approaches include effective training, centralised registration, notifications to users when creating a new record that is similar to an existing record, and use of MPI technology 10 20. When prevention is not implemented or is insufficient, institutions must have methods in place to detect duplicate records.…”

“…Finally, institutions should adopt error mitigation approaches, to prevent or reduce patient harm when duplicate or potentially duplicate patient records persist within systems. Methods for mitigating errors include notifying users who access a record that is similar to another record, alternating row colours in patient lists, requiring photo or biometric (eg, vein pattern matching) identification during patient registration and including an up-to-date picture of the patient in the record 8 20 22–26…”

“…While potentially duplicate records are technically correct, they may leave patients at risk for misidentification, or a wrong patient error. Extensive previous literature describes these errors, which commonly include ordering or administration of medication or care to the wrong patient 20 22–26 28–31. Duplicate records may also exist when the demographics are different; for example, a woman could have one record under her maiden name and one record under her married name.…”

Patient Misidentification in Oncology Care

“…The researchers noted that patient registration tended to focus on the technical aspects of the process (e.g., entering data) and that little attention was given to actually verifying patient identity (Bittle, Charache, & Wassilchalk, 2007). Errors can occur if the wrong patient is selected from the master patient list and the wrong armband is placed on the patient or if new patient information is incorrectly entered, which then appears on the armband.…”

Things Are Looking Up: A Ceiling Tile Project Inspires Patients, Family, and Staff & <b>Thursdays</b>

“…Researchers at the Johns Hopkins Hospital examined the extent to which the registration process contributed to patient misidentification and found that misidentification errors occurred 7-15 times per month, with the root causes being deficiencies in the information systems, inadequate personnel training, and lack of a master patient index. The researchers noted that patient registration tended to focus on the technical aspects of the process (e.g., entering data) and that little attention was given to actually verifying patient identity (Bittle, Charache, & Wassilchalk, 2007).…”