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Patient Misidentification: A Threat to Patient Safety in Healthcare

Patient Misidentification: A Threat to Patient Safety in Healthcare


The Incident

Identify The Issue You Selected From The Vila Health Simulation As The Potential Safety Threat.

Describe The Issue That Occurred With Sufficient Detail So That Leadership Has a Clear Understanding Of What Happened.

Identify The Implications Of Not Addressing Threat. Evaluate The Risk To The Patients, Employees, And Organization, If Patient Safety Threats Are Not Addressed. What Does The Health Care Safety Imperative Say About The Issue?

How Does The Health Care Safety Imperative Apply In This Case?

Which Regulatory Agencies Have Oversight About The Issue?

Analyze Regulatory Agencies’ Role And Impact On Organizations’ Patient Safety Programs. What Specifically Do The Regulations State About The Issue? For Example, You Might Consider The Joint Commission’s Npsgs.

What Impact Do Regulatory Agencies Have On Organizations’ Patient Safety Programs?

How Do Health Care Organizations Incorporate Regulatory Agencies’ Guidance When Establishing Reporting And Investigation Best Practices?

What Are The Potential Consequences To The Patients, Employees, And Organization, If The Hospital Fails To Correct The Threat? Analyze The Patient Safety Officer’s Role In Implementing Patient Safety Plans.

Explain The Role Patient Safety Officers Assume In Implementing Patient Safety Plans In Health Care Organizations. Clarify Your Responsibility And Role As The Patient Safety Officer In This Specific Instance Provide One Example From The Literature To Illustrate Your Points. Recommend Evidence-Based Best Practice Tools And Techniques To Reduce Or Eliminate Patient Safety Threats.

Describe Your Five-Point Plan To Reduce Or Eliminate This Patient Safety Threat. What Best Practice Tools Or Techniques Does Your Plan Include To Reduce Or Eliminate These Types Of Errors?


The healthcare industry has a vast array of responsibilities to perform within short deadlines. Patient identification is one such stage where the hospital fails badly. To correctly identify the patient and perform corrective procedures on them is as important as passing the exam. There is a huge chance that due to wrong identification, a patient may lose his life (Masri, 2018). Chances for wrong blood transfusion, testing errors, medication errors, wrong person procedures, and surgical interventions are some of the major problems surfacing in recent years.

As per ECRI’s analysis, the point of identification procedure at the first meeting is 72%, half of it during diagnostic procedures or treatment almost 36.95% and the rest 10% is while documenting the patient details. It was found that 7,600 wrong-patient misidentifications were occurring in a span of 3 years period in 181 healthcare organizations. About 9% of the events were not caught before time led to temporary or permanent harm, or even death (Stafseth, Tønnessen, & Fagerström, 2018). Around 45,000 to 97,000 patients die each year in the U.S. as a result of medical errors according to the Institute of Medicine (IOM).

Role Of Patient Safety Officer

One such incident surfaced in our hospital that had the potential to kill the patient. A 21-year-old patient named Frank Twain was admitted for skin allergy treatment on the bed which was of a patient who suffered cancer. The room number and bed with the name of the old patient were not removed. This made everyone believe that Frank Twain was having cancer and his doctor read his charts with started to treat him accordingly. A strong dose of Doxorubicin was given to the patient. It reacted to the patient and he fainted for a while. The incident alerted the doctor and the nurse was asked to recheck the record chart there it was found that the name on the wristband and the chart did not match. This was a near miss if the treatment was continued for cancer instead of the skin disease he was suffering there could have been irreversible consequences.

To prioritize the safety of the patient is their foremost duty. They have to follow the rules and laws of the hospital along with ensuring that the patient receives the best possible care. They are a support system in healthcare facilities; they shape the healthcare services so that mistakes can be avoided. They train the staff team for prioritizes patient safety (Neyrinck, & Vrielink, 2019). They design ways in which the staff can report the incidents. They can access individual staff performance and report the mistakes to the authorities or leaders. They also create policies and procedures to train their staff to ensure that patients receive quality treatment with no complications.

The senior leaders were informed about the incident. The data from past years were checked and it was confirmed that this was not the first misidentification case in this hospital’s history. It was time to take essential steps to strengthen the procedures. The consequences of procedure failure are completely borne by the innocent patient. They are at no fault and get the wrong treatment which can be fatal or irreversible sometimes. Improving the present scenario was essential for the safety of the patient. This was a clear mistake of admitting the patient to the other patient records. The patient’s identity was not confirmed before administrating medication.

National Patient Safety Goals (NPSGs) is a program commissioned by Joint especially looking after the national-level safety goals. It was created to look after a matter with high-priority areas in the context of patient safety. Its first work was to minimize the use of abbreviations that were confusing and misleading. To eliminate the potential for medical error they issued a list of abbreviations not to be used in the future. They are working with many institutions to minimize the causality due to misidentification. Some of the interventions were done from their end to understand the main reason and find a proper solution.

The Reporting Of The Incident

Improving electronic identifiers design can decrease misidentification- The role of technology cannot be neglected, using the physical and electronic identifiers within the electronic health record [EHR]. In the operating room or neonatal care, the wristband identifier plays a crucial role in identifying the patient. The identified wristbands should be legible with clear font and color-coding that are not degradable on exposure to water (Wistrand, Falk-Brynhildsen, & Nilsson, 2018). There were cases where the identifier was removed from the patient’s hand and there was no identification sign. Two-way confirmations should be introduced with name, age, and ID number along with the photo to be introduced.

Introducing new technology with automated Systems- To minimize the errors the automated level system check monitoring can be a progressive step. Barcoding and radiofrequency identification (RFID) tags help incorrect identification it also works in a real-time monitoring system. It has worked well in many hospitals by significantly reducing wrong-patient medication administration errors.

Improving monitoring and boycotting local cultural Processes – It is important to avoid working around the local culture of performing the same duty continuously. The staff performing duties often does not pay attention to proper procedures. Most of the time they do not scan the bar code or check the band before giving the medicines to the patient (Sonoda, Onozuka, & Hagihara, 2018). It is compulsory to scan the medicines and link them to electronic medicines records. Another thing noticed is that even before the patient has entered the operation room their details are already punched in the system. Continuous monitoring and regressive feedback have been compulsory to save lives from misidentification causalities.

Asking the patient’s relative or family to be present- In case of delivery of a baby, or operation, or any critical situation a patient should be assisted by someone trustworthy. The patient may or may not be conscious while operating thus to avoid error the partner should keep a close check on the condition of the patient along with monitoring the medicine and the medical board on the bed. They should express concern and ask questions about their correct procedures.

It’s a protocol to not ask patients leading questions- The nurses have to avoid asking “leading” questions while labeling their details. For example instead of saying “Are you, Samuel,” they should ask “What is your name”. Sometimes the patients overhear or are old and they give wrong answers leading to misidentification errors. Following the correct protocol is as essential as taking training to pass the nursing exam.

All these procedures are very important before labeling the patient. The correct identification can save a patient’s life. It’s the duty of the staff and the nurses to follow all the orders of the medical procedure and abide by the policy.


As per the case analysis of the incident, it becomes very clear that proper patient ID confirmation is the correct procedure for clinical care. The role of the medical institution is very essential in society it is considered that some of the most intelligent, fine, and skillful people work there. An incident of such a minute mistake only ruins the reputation and breaks the trust of people. The joint commission is working continuously towards eliminating even one percent error but a variety of interventions, for the same has very low impact and generally ends up in the same manner. The electronic identification will only work perfectly when applied at every process step. It is important to redesign systems for safety and reliability.


Masri, R. G. (2018). Neonatal nursing orientation: a two-tiered approach (Doctoral dissertation).

Neyrinck, M. M., & Vrielink, H. (2019). Performance of an apheresis procedure: The apheresis nurse-operator and nursing aspects. Transfusion and Apheresis Science, 58(3), 296-299.

Sonoda, Y., Onozuka, D., & Hagihara, A. (2018). Factors related to teamwork performance and stress of operating room nurses. Journal of Nursing Management, 26(1), 66-73.

Stafseth, S. K., Tønnessen, T. I., & Fagerström, L. (2018). Association between patient classification systems and nurse staffing costs in intensive care units: An exploratory study. Intensive and Critical Care Nursing, 45, 78-84.

Wistrand, C., Falk-Brynhildsen, K., & Nilsson, U. (2018). National Survey of Operating Room Nurses’ Aseptic Techniques and Interventions for Patient Preparation to Reduce Surgical Site Infections. Surgical infections, 19(4), 438-445.

Patient Misidentification: A Threat to Patient Safety in Healthcare


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