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September 27, 2016

An all-too-common nightmare: When doctors treat the wrong patient

Daily Briefing

    It's not uncommon for health care organizations to mix up patients, sometimes leading to harmful or even fatal consequences, according to a recent ECRI Institute report.

    ECRI Institute researchers analyzed 7,613 wrong-patient errors that occurred between January 2013 and July 2015 at 181 health care organizations. The organizations voluntarily submitted the data under a 2005 federal law that allows them to do so without fear of liability.

    William Marella, ECRI Institute Patient Safety Organization's executive director for operations and analytics, told the Wall Street Journal that wrong-patient errors are "a huge problem that the general public isn't aware of." He added, "Pretty much every clinician involved in your health care is at risk of making this kind of error."

    Hardeep Singh, a researcher at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine who advised the ECRI Institute on the report, said that there's more potential for such errors to occur as health care increases in complexity. "We're doing many more labs tests, more imaging tests, more procedures, and more transitions through the system," he noted.

    Report findings

    The report found that 91 percent of the errors were caught before they harmed patients. Most of the remaining errors resulted in temporary harm to the patient that required intervention, while ERCI said two of the errors may "have contributed to or resulted in [the] patient's death."

    ECRI cited several examples of wrong-patient errors, including:

    • A patient in cardiac arrest who wasn't resuscitated because the care team thought he was a different patient who had a  do-not-resuscitate order;
    • A patient who was not supposed to drink or eat but was provided with a meal and choked;
    • An infant who received breast milk meant for another infant, leading to the child being infected with hepatitis B.

    ECRI found that about 13 percent of wrong-patient errors occurred during the intake process, while more than 70 percent occurred during patient encounters.

    About 36.5 percent of the errors involved diagnostic tests, 22 percent involved procedures and treatments, 10 percent involved documentation, and about 3 percent involved care transitions.


    The report authors recommended that health care organizations:

    • Adopt standardized protocols to verify patients' identities, including using patient photos and standardizing how patients' names appear in EHRs, as well as possibly using bar codes to verify patients' identities prior to conducting certain tests and procedures;
    • Encourage staff to discuss errors openly in order to proactively spot and address problems;
    • Emphasize to staff that verifying patients' identities is an organizational priority and is crucial for patient safety;
    • Analyze whether their work processes are contributing to patient identification issues;
    • Not identify patients by their bed or room number, since those can sometimes change (Whitman, Modern Healthcare, 9/25; Beck, Wall Street Journal, 9/25; Minemyer, FierceHealthcare, 9/26; ECRI report, accessed 9/25).

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