The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the impending surgery. The patient spoke English and appeared to be of average intelligence.

In this institution, standard practice was that ambulatory surgery patients walked to the operating suite accompanied by a Registered Nurse (RN). The case was reported to AHRQ WebM&M by this circulating nurse, who noted, “I went to the surgical day care unit to meet my next patient. I picked up the chart that was next to this patient. The chart was correct for my next patient. I verbally stated the patient's name and this woman confirmed her name. She also confirmed other information, including the [type of] surgery.”

In retrospect, the nurse realized that she herself had supplied much of the critical information for patient identification, rather than asking the patient open-ended questions and insisting that the patient provide correct identifying information. And yet, the patient affirmed all the nurse’s queries. Upon reflection, the nurse realized, “This patient was so anxious she was not actually hearing much of anything I said to her. She continued to agree and confirm whatever I said to her. The error on my part was that I stated her name, and did not check her wristband.”

At the end of the identification procedure, the nurse walked the patient to the operating room (OR) suite and had her positioned on the OR table. The certified nurse anesthetist checked the patient's wristband and alerted the nurse to her error – the chart the RN had picked up was not that of the correct patient but had inadvertently been left next to her. The nurse noted, “I was shocked. I apologized, explained she was in the wrong room, and asked that she return to the waiting area. I had to take the patient off the OR table and return her to the surgical day care unit.”

Luckily, the error was caught and the patient was not harmed. As the nurse recalled, “I learned a serious lesson, which I certainly had been taught in nursing school, which is to always check the wristband. I don't know just how far this mistake would have gone, because the patient is frequently asleep when the surgeon enters the suite. I now reinforce the importance of always checking the wristband whenever I have an opportunity to with my colleagues.”

by Marilynn M. Rosenthal, PhD

This is a startling, and sobering, case of patient misidentification. As often happens with even serious near misses and adverse events, the incident involved a confluence of several errors, each of which may seem relatively minor itself: first, the wrong patient chart was placed by the patient’s bedside; second, the RN did not question that the chart could be incorrect; third, the RN failed to check the patient’s wristband; and fourth, the RN failed to ask patient identification questions in an appropriate way. As is also often the case, the error appears to have been made by a conscientious professional who was remorseful about the error.

In this case, patient misidentification was further complicated by the fact that this patient’s responses affirmed the nurse’s queries about name and procedure. Apparently, the nurse read the information from the wrong chart and the patient, in her anxiety, confirmed the wrong information. Fortunately, another member of the clinical team (the nurse anesthetist) did check the patient’s wristband. In addition, the RN admitted and apologized for her mistake, following current calls for disclosure and transparency in the setting of serious errors and unexpected complications.(1)

Epidemiology of Patient Misidentification
The specific errors of this case, failure to check for the correct chart, failure to check the wristband, and failure to obtain patient information correctly have received scant attention in the literature. Moreover, they rarely appear in incident reports. When unchecked, such errors result in major patient misidentifications such as wrong site, wrong person, or wrong procedure surgery.(2) The Joint Commission on Accreditation of Healthcare Organization’s (JCAHO’s) sentinel event statistics include 240 reported cases of such events.(2) A recent case study of a major patient misidentification reported that (when the JCAHO statistics included only 150 such events) 10 of those cases involved wrong patient procedures.(3) This small number almost certainly reflects significant under-reporting.

The only other published estimates of major misidentification errors come from transfusion medicine and, to a lesser extent, studies of medication errors. In one study that used a variety of record review approaches, “wrong drug or patient” errors represented 4% of all medication errors among hospitalized medical patients.(4) The chance that a patient will receive a blood product intended for another patient is roughly 1 in 20,000.(5,6) Chance blood group compatibility reduces the frequency of serious transfusion reactions to about 1:600,000, with roughly two dozen fatalities in the US annually. These deaths are particularly disturbing since “a significant number...are attributable to misidentification of patients or units and are preventable by obsessional attention to clerical details.”(7) Given that blood banking generally has greater safeguards against errors of any kind, the frequency of major misidentifications in other clinical settings is likely much higher.

Why are so many misidentification errors not reported? These errors likely are not seen by front-line workers as reportable or, as in this case, no harm came to the patient so it was not deemed to be worth the time to fill out an incident report. There also may be the inhibition caused by fear of blame (8), or perhaps high levels of embarrassment since the errors seem so simple to prevent.

“Check the Wristband”
The most fundamental omission in this case was failure to check the patient’s wristband identification. Importantly, proper identification includes other steps, such as checking the patient’s name against the chart and also the OR schedule or, as necessary, the medication or blood product to be administered. For instance, if the wrong patient is about to be taken for a procedure, she may still have the correct wristband and chart accompanying her.(3) A recent study from the laboratory medicine literature reported complete adherence to optimal patient identification protocols in only 62% of 660 hospitals.(9)

While not a defense of the omission in this case, it is worth noting that wristbands themselves often have errors. A national sample of 712 hospitals in 1991 estimated error rates for conventional patient identification wristbands at 5.5%.(10) Half of the cases involved absent wristbands, but the other half included more than one wristband with conflicting data (18.3%); wristbands with incomplete (17.5%), erroneous (8.6%), or illegible data (5.7%); and, rarely, patients wearing wristbands with another patient’s data (0.5%). In other words, even with 100% compliance with the recommended strategy of checking wristbands, 1 in 200 patient misidentifications might go undetected, especially in settings such as this one, where none of the personnel interacting with the patient would be likely to know her clinical situation. Reassuringly, a recent study from same group found that continuous monitoring resulted in significant decreases in wristband errors.(11) In this study, a constant reminder to check wristbands reduced wristband errors more than 50% in a 2-year period.

Lessons Concerning the Patient as a Source of Accurate Information
Today there is much emphasis on the role of the patient, the importance of a well-informed patient and of clear informed consent. These are all laudable goals, but this case illustrates the difficulties in regarding the patient as the keeper of her own safety in the acute-care setting. Here we see an anxious patient who is unable to recognize that her identifying information, being recited to her by the nurse, is incorrect. In such situations, patient anxiety should be seen as a warning signal that the patient may be unable to participate in the desired manner, the result being “Uninformed Consent.”(3)

In this case, the initial patient misidentification is further compounded by the fact that this patient’s responses affirmed the nurse’s queries about her name and procedure. The patient’s responses undoubtedly reflected her anxiety about the impending surgery. Importantly, such anxiety occurs in many settings in medicine, though is perhaps most appreciated in the setting of conveying bad news, especially in oncology.(12) Recognition of the extent to which patients can be distracted from understanding or retaining new information has led to work on structured approaches to conveying information to avoid subsequent misunderstandings.(13) Even in the absence of anxiety, patients may respond inaccurately to closed-ended questions (eg, “Are you here for arthroscopy today?”). Clinicians must take the time to ask patients open-ended questions (“Tell me your name...What procedure are you having done today?”), allowing them to describe in their own words what they understand to be the treatment they are about to receive or undergo.(14,15) In the present case, asking an open-ended question could have ended the confusion or alerted the nurse to the patent’s anxiety.

Technology as a Solution
James Reason, who has studied a wide range of human errors and systems factors that can reduce them, states: “Leaving out necessary task steps is the single most common human error type. Certain task steps possess characteristics that are more likely to promote omission than others. Rooted as it is in the human condition, fallibility cannot be eliminated but its adverse consequences can be moderated through targeted error management techniques.”(16) He suggests that it is difficult to pinpoint all the reasons for an omission, even on the part of the error-maker. He offers two approaches to reducing such errors: a well-designed reminder system and “forcing functions” (eg, electronic devices) that block untoward actions.

There is increasing interest in and information about the use of barcoding to reduce patient identification errors.(17) Such technology, combined with Web-based electronic medical records and wireless computing, offers significant opportunities to reduce patient identification errors.(18) As with any new technology, protection against error is not perfect,(18,19) and new types of errors may even be introduced.(19)

Solutions: Reminder Systems and Learning from Near Misses
I was particularly impressed by the nurse’s forthright admission of error to the patient and willingness to learn from the mistake. However, if all that results is a single individual vowing never to slip up again, the system will remain primed for another error, as vigilance wanes over time and the inevitability of slips becomes evident. Upon hearing of a near miss like this, systems should promote the relevant front-line workers to develop solutions that would prevent such errors in the future. Here, it would have been useful for the RN, the nurse anesthetist, and the unit clerk to meet and work out a unit reminder system. Better yet, they could institute Near-Miss Rounds,(20,21) or initiate a program of continuous wristband monitoring, as has been done elsewhere.(11)

Take-Home Points

Insight: Patient misidentification is surprisingly common but remains among the least studied of important medical errors.

Short-term Solutions:

• Ad hoc team to address specific issues
• Regular Near-Miss Rounds
• Reminder system implementation

Long-term Solutions:

• Barcoding technology
• Electronic, wireless Web-based patient records linked to all procedures

Marilynn M. Rosenthal PhD
Adjunct Professor
Department of Internal Medicine
University of Michigan Medical School
Ann Arbor, Michigan

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