A recent report from the ECRI Institute, a non-profit research group that studies patient safety, found that medical mix-ups are common and can have deadly consequences. The report, according to the Wall Street Journal, analyzed 7,613 cases of so-called “wrong-patient errors” at 181 healthcare organizations from January 2013 to July 2015. The cases were submitted voluntarily under a federal law that lets providers share safety data without fear of professional liability claims, and most likely represent only a fraction of the mix-ups that occurred, ECRI officials said.
Examples of mistakes discussed in the report include a patient in cardiac arrest who was mistakenly not resuscitated because clinicians confused him with a patient who had a do-not-resuscitate order on file. Another patient was given the okay to undergo surgery based on a different patient’s records and was found dead in his hospital room the next day. Still another patient was given another individual’s hypertension medication – at 10 times the usual dose. A patient who wasn’t supposed to eat or drink was given the wrong meal tray and nearly choked. And an infant was given expressed breast milk from the wrong mother and was infected with hepatitis.
“This is a huge problem that the general public isn’t aware of,” said William Marella, executive director for operations and analytics at the ECRI Institute's Patient Safety Organization. “Pretty much every clinician involved in your health care is at risk of making this kind of error.”
Although safety initiatives have been responsible for many improvements in recent years, opportunities for ID mix-ups are increasing as healthcare becomes more complex. “We're doing many more labs tests, more imaging tests, more procedures and more transitions through the system,” explained Hardeep Singh, a patient-safety researcher at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, who was an advisor on the report.
Of the 7,613 mix-ups studied, 91% were caught before patients were harmed, according to the Wall Street Journal, which analyzed the ECRI report. Two were fatal. The report found that about 13% of identification errors occurred during registration, when a duplicate record might be created for the same patient or information from two patients was co-mingled in one record. More than one-third of the mix-ups studied involved diagnostic tests such as X-rays and lab work; 22% involved treatments and procedures. In some cases, a patient’s wristband was wrong, missing, illegible or simply not checked.
The report urged all healthcare facilities to adopt standardized protocols to verify patient identities, emphasize their importance to all staff members and discuss errors openly to learn from them. It also suggested standardizing how patients’ names are displayed in electronic records and including patient photos.
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