Abstract

Background: Patient misidentification prevails in daily practice and remains a critical issue in health care. Being knowledgeable about how to accurately identify patients and comply with identification processes is critical, particularly in countries where patients have similar names. A study was undertaken to examine the knowledge levels of and compliance with the patient safety goals and policies and procedures of the clinical and nonclinical staff. Materials and Methods: A cross-sectional survey and an observational audit design were used at a specialist and research hospital in the Saudi Arabia to assess knowledge levels and compliance rates of appropriate patient identification methods. Results: The majority of healthcare providers (n = 350, 87.1%) and almost half of non-healthcare providers (n = 186, 47.8%) reported high levels of knowledge of patient identification standards, including the need to use two patient identifiers. However, audit results revealed that health-care providers used two identifiers in only 33 observations (18%), with the majority (147 observations, 82%) of health-care providers checking the patient's name only and not his/her medical record number. Conclusion: The results highlight the need for further attention to improper identification of patients, including understanding the causes and ways to enhance the translation of patient identification standard into practice.

Background

Improving the accuracy of patient identification continues to be a priority focus in health-care organizations and a National Patient Safety Goal for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).[1] However, patient misidentification prevails in daily practice and remains a common problem and critical issue in health care.[24] Misidentification is referred to as the process of identifying (something or someone) incorrectly[3] and is a root cause of wrong-patient errors occurring virtually in all stages of treatment including medication errors and wrong-patient procedures.[4,5] Wrong-patient errors as a result of misidentification have been reported during surgical procedures (e.g., wrong patient and wrong limb),[6,7] oncology with chemotherapeutic agents and radiation,[8,9] laboratory[10,11] and transfusion medicine,[12,13] neonatal intensive care,[14] and pathology.[15] More recently, JCAHO reported 94 (out of 801) sentinel incidents associated with wrong patient, wrong site, and wrong procedure, ranking third out of all sentinel events in 2018.[16]

Patient misidentification can lead to harm and mortality,[2] as one study revealed that 9% of the 7600 wrong-patient events led to temporary or permanent harm, and in some cases death.[17] Specifically, the misidentification of patients have been consistently associated with the risk of medical or surgical procedures performed on the wrong person, diagnostic errors where diagnoses or test results are given to the wrong patient, or unnecessary delays in care delivery.[3,18,19] In the latter situation, the delay in care for those patients that require timely diagnosis and treatment (i.e., acute myocardial infarction, stroke, hemorrhage, etc.) can result in major harm and death.[3,18,19]

Patient misidentification often occurs because of the name similarity and structure as health-care providers (HCPs) can be confused due to similar names.[35] Patient misidentification also occurs when there is an absence of a patient identification process.[2] Referred to as an “identification crisis,”[3] wrong-patient errors are preventable.[3,4,17] Patient identification processes can prevent wrong-patient medication administration.[4,20] A strategy with a multi-prong approach was implemented recently to reduce patient misidentification leading to the wrong-person error.[3,21,22] Strategies within efforts include the use of at least two identifiers (e.g., patient's name and date of birth) and not the patient's room number or physical location to verify a patient's identity, and the use of barcode verification and wristbands before the administration of care.[1,3,4,23]

The key to accurate patient identification is having knowledgeable staff who are educated about the correct identification processes.[3,4] Patient misidentification that results in wrong-patient errors can be related to poor knowledge, education, or training[24,25] and lack of compliance with the appropriate processes and procedures for accurate patient identification.[26,27] Being knowledgeable about how to accurately identify patients and complying with identification processes are critical, particularly in countries where there are patients having similar names.[3] In this context, a study was undertaken to examine the knowledge levels and compliance with the patient safety goals and policies and procedures of clinical and nonclinical staff.

Materials and Methods

Study design

A cross-sectional survey and observational audit design were used in this study to address the research questions. The research study was approved by the Research Ethics Committee at King Faisal Specialist Hospital and Research Center (KFSH and RC, Riyadh, Kingdom of Saudi Arabia) on October 8, 2015, and the study was conducted over 2 years, with the final study report approved on April 27, 2017. Completion of the survey served as implied consent.

Data collection and analytical methods

Survey questionnaires

A survey was developed to examine the knowledge levels of the patient safety goals and policies and procedures of clinical staff associated with accurate patient identification. The survey consisted of demographic questions on position (clinical and nonclinical), the overall number of years working, years working in the current position, age, and gender. The knowledge questions were derived from the First International Patient Safety Goal of the Joint Commission International[28] and offered multiple-choice options; another answer category was included in some of the questions. Supplementary File 1 provides examples of the questions included in the knowledge domain.

The survey tool was pilot tested for interrater and test–retest reliability before being sent out electronically using the Vovici Survey System (version 7, Verint Systems).[29,30] The tool was pretested in the in vitro fertility, radiation, and phlebotomy clinics with a total of 22 providers and revised according to their feedback.

Sample size calculations based on achieving a 95% confidence interval were 363 surveys from HCPs (n = 6510) and 354 from non-HCPs (n = 4440). A convenience sampling method was used.[31,32] Descriptive statistics were used to calculate frequency counts and percentages.

Observational audits

Observational audits were conducted to assess practice compliance with the enactment of patient identification standards. HCPs were not aware of the purpose of auditing to avoid any potential bias if they knew that they were audited.

An audit tool was developed in accordance with the organization's policy, Joint Commission International Standards,[28] and World Health Organization Guidelines[5] and contained questions linked to these specific guidelines, policies, and procedures. Overall inclusion criteria for audited HCPs included nurses, technicians, technologists, phlebotomists and wardclerks who had been in the organization longer than 3 months and were not students. The inclusion criteria for the patients were male and female patients above 14 years of age, unresponsive patients, and those with a mental or physical disability with the presence of the guardian. The study aimed to sample 40–60 cases to permit meaningful comparison of current practice with the agreed standard.

The observation component was conducted in clinical areas that were identified as high risk for patient misidentification. These areas were targeted for the observational audit and included interventional and outpatient radiology, in vitro fertility, treatment area of oncology, radiation therapy, acute and chronic hemodialysis, day surgical unit, pre-anesthesia, endoscopy, dentistry, and phlebotomy. Within these targeted areas, the sampling mode to conduct the observational audit used a simple random sampling type that used the organization's Q-Matic System that generated numbers with every third number assigned a patient to be included in the audit. Each healthcare professional was audited for two to four patients that were identified in the random sampling. Trained staff from the clinical audit section at quality management division at the participating health-care organization conducted the audits. The auditors recorded the location, discipline, and whether the provider (1) used two identifiers to identify the patient, (2) checked the patient's name and medical record number (MRN), and (3) asked the patient and guardian to verbalize the patient name and medical record number.

Results

Survey questionnaires

A total of 402 HCPs and 389 non-HCPs completed the surveys. The distribution of health-care professionals who participated in the survey was 309 nurses, 20 physicians working in medical and surgical services, 28 pharmacists, 19 technologists, 22 phlebotomists, and 2 dieticians. The distribution of non-HCPs was 219 support staff and 169 administrative staff. Table 1 provides the demographics of the survey respondents. The desired sample size for the two cohorts was achieved, so the datasets were analyzed.

Table 1:

Survey participant demographics

Survey participant demographics
Survey participant demographics

Survey results revealed that the majority of HCPs (365, 90.8%) and non-HCPs (259, 66.6%) correctly answered the First International Patient Safety Goal and that two patient identifiers should be used (350, 87.1% and 186, 47.8%, respectively). The majority of the respondents from both groups were able to identify correctly that the patient's MRN and full name are the primary identifiers to be used. HCPs and non-HCPs also selected the correct response to having proper identification before treatment and procedure (384, 95.5% and 337, 86.6%, respectively) and to avoid near misses or adverse incident events (260, 64.7% and 143, 36.8%, respectively).

Survey respondents provided several situations where patient identifiers should be used, including during blood transfusion, patient admission, medication administration, surgical or radiological procedures or operations, and handling critical laboratory results. Regarding when to identify patients in emergency situations or when they are comatose, the majority of responses were correct including that both should be carried out simultaneously (203, 50.5% for HCPs and 187, 48.1% for non-HCPs).

The survey question on the best time to place the labels on the specimen tubes after the patient identity is determined rendered a variety of responses, with close to 50% of HCPs reporting before specimen tubes collection and after specimen tube collection. The majority of HCPs (369, 91.8%) and non-HCPs (219, 56.3%) answered that they involved the patient, spouse, or family member in the process of patient identification. A variety of narrative responses were also provided including involving the spouse or family member with patients who are cognitively impaired, developmentally delayed, mentally unstable, or have language and communication barriers.

Several causes of wrong-patient identification were identified by survey participants, with the most commonly reported being the similarity of patients' names, miscommunication, distractions, multitasking, not following hospital policies relevant to patient identification, and applying shortcuts while doing tasks.

Supplementary File 2 provides more details on the survey responses.

Observational audits

The final audit sample involved 180 observations and included 146 nurses and 34 technicians in a variety of clinical areas [Table 2] over a 1-year period (November 2015 to October 2016). Specifically, the audit involved observing for checking the patient's MRN and full name.

Table 2:

Number of observations per clinical area

Number of observations per clinical area
Number of observations per clinical area

Audit results revealed that HCPs used two identifiers in 33 observations (18%), with the majority (147 observations, 82%) of HCPs checking the patient's name only and not the MRN. Further, HCPs used the first and second name most of the time and not the full name of the patient, as required by the hospital policy and the practice standards.

Discussion

Despite relatively high levels of knowledge of evidence-based patient identification practice standards, this knowledge is not necessarily translated into practice. Specifically, the survey results included that HCPs were knowledgeable about identifying patients correctly as the First International Patient Safety Goal and the rationale for needing practice standards and that two patient identifiers are acceptable as well as contributing factors to patient misidentification. However, audit results revealed that most HCPs checked the patient's name only, with less than 20% using two patient identifiers or asking the patient or guardian to verbalize the patient's name and MRN. Although no similar study could be located in the literature, it has been reported that poor knowledge and education[24,25] and lack of compliance with the appropriate processes and procedures for accurate patient identification[26,27] lead to patient misidentification, which can cause harm and death.

These results warrant further attention on improper identification of patients, including understanding the causes and ways to enhance the translation of proper patient identification standards into practice. This future work can draw from a series of systematic reviews on evidence-based practice research in the health-care sector that have delineated several barriers to the translation and uptake of evidence into practice.[3340] Common factors from these reviews include a lack of time and resistance to practice change for HCPs as well as administrative and resources constraints. Both of these factors were influenced by a lack of support and investment in changing practice by the administration and high workloads of HCPs.

Since the completion of this study, the Quality Management Department at KFSH and RC has used a series of improvement strategies including awareness campaign on hospital television, electronic posters, and brochures. Patient identification bracelets were implemented for all patients and education sessions conducted for HCPs. Secret shoppers who are unknown auditors of the practice of HCPs provided data on a quarterly basis to leadership to enhance the compliance of patients' identification standards of practice. Plans are underway to determine if these strategies have made an impact on process measures (e.g., proper identification of patient using at least two identifiers) and outcomes measures (e.g., harm caused by misidentification of patients).

The study was able to achieve its targeted sample sizes for both the knowledge assessment and the practice audits. The practice auditors audited the practice in outpatient clinics and procedural areas. Further future audits will be considered for the inpatient units to evaluate the knowledge and practice in this setting as well.

Conclusion

Although HCPs and non-HCPs reported high levels of knowledge of patient identification practice standards, the knowledge was not always translated into daily practice. A future examination is needed to determine why this knowledge-to-action gap exists and to develop efforts to enhance HCP's compliance with the standards of practice associated with patient identification. These efforts have the potential to decrease patient misidentification and the associated potential for patient harm.

Acknowledgment

The research team would like to acknowledge the contribution of Dr. Lianne Jeffs in the development of the initial draft of the article and revising it critically for important intellectual content.

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Financial support and sponsorship

The authors disclosed no funding related to this article.

Conflicts of interest

The authors disclosed no conflicts of interest related to this article.

Supplementary material

Supplementary material is available with the article online at jqsh.org.

Author notes

For reprints contact:reprints@medknow.com