Misidentification of a patient is a serious safety and legal issue for healthcare.
Misidentification can occur:
(1) on arrival
(2) at registration
(3) prior to an event (specimen collection, drug administration, surgery, etc)
(4) in an ancillary department (radiology, pharmacy, laboratory, etc)
Risk factors for misidentification:
(1) multiple patients with the same or very similar spelling of last name
(1a) especially if patients are on same ward
(1b) may include multiple family members, especially twins or triplets
(2) failure to or unable to use at least 2 data items for identification (ideally with at least one requiring positive input from the patient)
(3) bar-code label or reader failure
(4) staff unfamiliar with patient, including frequent movement of patient
(5) time pressure, including emergency
(6) patient unable to provide information (coma, medication, etc)
(7) silo issues (breakdowns in communications) between departments
(8) inadequate policies and procedures for patient identification
(9) failure to follow policies and procedures for positive patient identification
(10) software failure (for example, think one item selected but another one instead)
(11) failure to report or correct misidentification
(12) poor or incomplete training
(13) problem with armbarnd (incorrect armband placement, illegible or removal of armband
(14) too many duplicate medical records for the patient
(15) too many patients with similar last names in computer system
(16) human error made at registration
(17) misinformation from patient (behavioral issues, intentional)
(18) name and/or gender change
