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Two Patient Identifiers and Patient Safety: A Case of Mistaken Identity

Author: Dr. Matt Scanlon
Associate Professor of Pediatrics- Critical Care, Medical College of Wisconsin
Associate Medical Director of IS, Children's Hospital of Wisconsin

The concept of checking two or more patient identifiers is routinely cited by safety organizations around the world. Unfortunately, this concept sends the wrong message to care providers, undermining safe care.

A central component of many safety plans is the practice of checking two or more patient identifiers. This concept has been the focus of countless safety campaigns in the hopes of avoiding the administration of medications to the wrong patient, wrong patient procedures and other potentially preventable errors and harm. Which would all be wonderful if it was meaningful. However, science and reason suggest otherwise.

Two scenarios, one hypothetical and one not, might illustrate this case of mistaken identity. First, imagine, for a moment, a small bus carrying a group of holiday travelers. The bus is in a motor vehicle collision and five of the travelers are injured, each thrown from the vehicle without any form of identification. Emergency medical services transport the five passengers to a nearby hospital for care. There, they are triaged, their initial injuries identified, and a plan of care is made. All this work is challenged by the fact that none of the patients speak a language for which translator services are readily available.

Unfortunately, in the absence of paper identification or means to communicate, there is no means of identifying the patients and thus further care is halted… correct?

“Nonsense,” you protest.

But isn’t the knowledge of their respective identities the only way to assure safe care?

We’ll come back to this question in a moment.

In scenario two, picture a state of the art hospital for sick children. Sadly, several children with oncologic disease are hospitalized for the holiday. The three children in question are each well-known “chronic” patients who have been hospitalized months collectively on the oncology unit. In fact, two nurses who have cared for the children hundreds of hours volunteered to work the holiday shifts knowing the children were admitted.

Surely these caring, dedicated and skilled nurses will verify the patients’ identities, assuring safe care. Right?

“Nonsense,” is the answer you want to bet money on. The interesting part is why…


The goal of “two patient identifiers”

Let’s return to scenario one. The creators of the “two patient identifiers” safety initiative were not intent on preventing the care to the hypothetical accident victims. The real goal is to assure each patient only receives the care appropriate for them as individuals (Table 1).

Patient and Initial Findings

Proposed Initial Care Plan after the “ABCDs”

1. Scalp laceration, agitation

A. Radiographic imaging of right wrist

2. Open fracture of lower left leg

B. Head CT and “load” of seizure medication

3. Prolonged seizure

C. Observe while awaiting a translator

4. Swollen right wrist with tenderness

D. Head CT, cleaning of head wound with eventual suturing if head CT normal

5. No clinical signs of injury or illness

E. Radiographic image of lower left leg, prophylactic antibiotics

Table 1. Findings after initial triage of unknown trauma patients and potential plans of care, not matched.

Thus, for each of the “unknown” patients, the care team has to match the proper therapeutic and diagnostic plan to the patient. Having their real identity would facilitate the matching process. But the fact the patients are likely assigned a temporary identification for the purpose of enabling matching reinforces the fact that the real goal is matching, not identification per se.

“But what about the children in scenario two?” you ask.

In a study by Karsh and this author, a total of 203 nurses were surveyed across three care units in each of two children’s hospitals. As part of the survey, they were asked:
1. In actual practice, to what extent do you find yourself routinely having to work around protocol for “stage”?
2. In actual practice, to what extent do you find yourself routinely having to break protocol for “stage”?
3. During an emergency situation, to what extent do you find yourself having to work around protocol for “stage”?
4. In an emergency situation, to what extent do you find yourself having to break protocol for “stage”?

These questions were posed for three medication safety practices: checking the patient’s identification before administration, checking the correct Medication Administration Record before administration, and documenting the administration of the medication. These questions were asked on a seven-point Likert scale, from “0 - Not at all,” to “6 - A Great Deal.” All responses were voluntary and anonymous, and are displayed in Figure 1.

Figure 1. The percentage of nurses who responded that they broke or worked around the policy of “checking a patient’s identification” before administering a medication, either a little or some of the time, or a moderate amount of the time, or more.

In emergent scenarios, over 90% of the surveyed nurses replied that from a “little” of the time or more they worked around the policy, with nearly 82% of nurses admitting they broke the policy. In the same survey, the nurses revealed they were more likely to workaround or break the policy the more dissatisfied they were with the policy (OR 3.37; 95% CI 1.55, 7.30).

“Dissatisfied?” you ask. “What does that mean?”

When queried, the nurses were less likely to comply if they viewed the policy as irrelevant. Specifically,
they consistently felt it was ridiculous to keep checking identification for patients whom the nurses knew who they were.

And thus, the problem of mistaken identity: because this safety initiative is labeled and presented as being about checking patient identification, nurses largely see the practice as unimportant and, in some cases, insulting to their knowledge.

Oh, and the results were essentially identical regardless of which unit or which of the two hospitals were surveyed.


What does this mean for patient safety professionals?

To paraphrase Dr. Seuss, we should mean what we say, and say what we mean. If the intent of this behavior is to match patients and their care, then data would suggest telling providers what we really want them to do (match patients and care) and NOT something that may help with the ultimate goal (check patient identification).


Authors note: the data and concepts here are available in a different format in Alper SJ, Holden RJ, Scanlon MC, et al. Self-reported violations during medication administration in two paediatric hospitals. BMJ Qual Saf 2012; 21:408-415. This study was funded in part by a grant from the Agency for Healthcare Research and Quality (R01 HS013610, Karsh PI).

This blog entry is published under a Creative Commons license (CC BY-NC-SA 3.0). It can be freely shared and adapted, as long as the work is attributed. The work is not available for commercial purposes