Registration-associated patient misidentification in an academic medical center: causes and corrections.
BACKGROUND
Proper patient identification is a major factor affecting patient safety in any health care organization.


METHODS
An interdisciplinary team, using three Plan-Do-Study-Act (PDSA) cycles, reviewed the incidence of patient misidentifications resulting from registration process errors. Retrospective and prospective data were collected to determine the incidence among inpatients and outpatients.


RESULTS
Registration-associated patient misidentification errors occurred 7 to 15 times per month. Information systems deficiencies, inadequate training, and the lack of a single master patient index were among the root causes identified. After three PDSA cycles, the incidence rate for registration-associated patient misidentification errors declined for inpatients (80.5%) but increased for outpatients (30.2%).


CONCLUSIONS
Through an iterative process as implied in the PDSA cycle, registration-associated patient misidentification errors for established Johns Hopkins Hospital patients were dramatically reduced. A checklist is provided for other organizations to assess their vulnerability to registration-associated patient misidentification errors. The checklist suggests, for example, that organizations strive to develop a single master patient index and limit access to registration systems to staff with proper training and performance expectations.
Bittle
Mark J
MJ
Johns Hopkins University School of Medicine, Baltimore, USA. mbittle@jhmi.edu
Charache
Patricia
P
Wassilchalk
Daniel M
DM
D000046:Academic Medical Centers; D006801:Humans; D033183:Interdisciplinary Communication; D019300:Medical Errors / Q000517:prevention & control; D010355:Patient Identification Systems / Q000458:organization & administration*; D017064:Process Assessment, Health Care / Q000458:organization & administration*; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000458:organization & administration*