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Patient Identification Errors. National Quality Strategy

Patient identification is regarded as an essential process in healthcare facilities, directed at ensuring the correspondence between patients and respective medical procedures via accurate communication of patients’ information. Patient identification errors (PIEs) can result in significant physical and mental harm and additional care cost, thereby complicating the treatment and nursing workflow. Thus, it is evident that efficient and safe care should begin with patient identification, which requires developing appropriate organizational policies and preventive strategies. This paper aims at analyzing the scenario from the Vila Health: Patient Safety simulation activity and its implications for patients and the organization, determining the patient safety officer’s role, and providing practical recommendations.

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The Description of the Issue

Patient misidentification can be a root cause of numerous severe medical problems, especially medication administration errors, wrong tests, and prolonged stay. The given scenario involves a professional conversation between Kyra Dilley, a patient safety officer, and Virginia Anderson, a nurse manager, employed at Independence Medical Center. Precisely, while performing usual safety rounds at the pediatric unit on the eighth floor, Dilley noticed the resemblance of patients’ names, namely, B. Moore and B.R. Moore, who are in rooms directly opposite one another. Furthermore, Dilley learns from the nurse manager that the birth dates of these individuals are similar as well. While discussing the measures to address this complicated situation, Anderson notes that there is a temporary problem with understaffing, which required her to make notes in both shift charts concerning these patients. These notes are needed to make various shifts aware of the concern and ensure that these patients have two different nurses.

Risk Evaluation

The Agency for Healthcare Research and Quality (AHRQ) adopted The National Quality Strategy (NQS) in 2011, which pursues three fundamental aims used to evaluate and direct the national and local healthcare efforts. The first goal implies enhancing care quality and patient satisfaction by making it more reliable, safe, and patient-centered (“About,” 2017). The second aim specifies improving the USA population and communities’ health by supporting evidence-based interventions responding to social and environmental factors. The final objective assumes decreasing the cost of appropriate care for persons, families, organizations, and the government. Hence, at least two imperatives, that is, Better Care and Affordable Care, are directly related to patient identification. In particular, as mentioned above, PIEs result in various physical and mental damages for patients and their deteriorated satisfaction. These mistakes are also connected with enlarged medical expenses for individuals and organizations, which contradicts the third aim. To advance these aims, the NQS determines six priorities, the first of which demands guaranteeing safer care by diminishing harm caused in care delivery.

Governmental agencies accountable for the prevention of PIEs include the Joint Commission (JCAHO), National Committee for Quality Assurance (NCQA), and the Iowa Department of Public Health. For example, the JCAHO operates to ensure that medical organizations and facilities deliver a sound quality of care. Specifically for PIEs, the Joint Commission recommends applying two patient identifiers before providing treatment or services, including a patient’s full name, medical identification (ID) number, or birthdate (“Two Patient Identifiers,” 2021). Other examples of identifiers can include a telephone number, address, and barcoding. In addition to providing accreditation and outlining goals, the JCAHO contributes to organizations’ programs by conducting consultations and sharing relevant and useful information. Finally, the agency assesses and approves different educational and in-service programs and reviews their effectiveness. The data and statistics delivered by the Joint Commission and other agencies can be used in reports that concern misidentification incidents and target developing improvement measures.

The organizational risks that may be inflicted if the issue will not be addressed primarily comprise continued medication and the increased possibility of procedural errors and wrong blood transfusion. This, in turn, can cause an adverse impact on patient satisfaction and health, including mental disorders, disabilities, and even deaths. The study by Lippi et al. (2017) states that over 22 percent of 6705 identification errors occurring in the 120 laboratory services produced an unfavorable clinical impact. Besides, one report specifies that hospitals lose around $17 million a year because of denied insurance claims (Choudhury and Vu, 2020). Finally, such problems often result in lawsuits, penalties, fines, amplified regulatory oversight, and the loss of reputation or even accreditation.

Patient Safety Officer’s Role

The central task of patient safety officers is to ensure the delivery of quality healthcare for patients by helping form practices following which errors are averted. While implementing particular safety improvement plans, the officers aid in shaping the team’s vision and prioritize challenging areas needing urgent consideration. They also promote collaboration between staff members and clinical departments to improve the report of incidents. Moreover, leaders coordinate safety initiatives, consult with other medical professionals and experts, and develop practical methods for propagating best patient identification practices (“ASHP Statement,” 2014). Finally, they integrate the most recent research and relevant data into plans to increase awareness among healthcare providers.

In the given instance, the responsibilities of patient safety officers embrace cooperating with all healthcare professionals to improve patient identification, staff education, and research. In particular, the officers should serve as an authoritative resource regarding all issues associated with patient identification and lead safety committees and meetings. Besides, they should review existing policies and procedures related to room assignment and support active communication with nurses appointed to each patient. Furthermore, leaders are liable for collecting and examining data linked to the problem and the best preventive techniques and strategies. Finally, the officers should utilize respective advanced technologies such as scanning wristband barcodes or referential matching software. A meta-analysis by Khammarnia et al. (2015) concluded that using wristband barcodes led to over 57 percent reduction in medical mistakes. Another study revealed that from 67,289 identification errors, almost 50 percent was due to the ID bands’ absence (Rezende et al., 2017). It is also worth noting that to provide the appropriate use of wristbands, safety officers should conduct a detailed instruction for personal and patients and monitor their efficacy.

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A Five-Point Recommendation Plan

  1. The first recommendation is related to the organization’s policies and procedures regarding patient identification. The hospital should follow the Joint Commission’s advice and use two identifiers. If names and birth dates are similar, it is relevant to consider the third one, for example, ID numbers. The institution should develop and provide clear, standardized protocols for the patient identification process, rounding, checking, and labeling of containers utilized for patients’ different specimens. In particular, the policy should specify that specimen labeling or relabeling can be conducted only by accountable workers. Besides, room assignment policies are to be reviewed and adjusted to prevent confusion between patients and assigned nurses.
  2. The second recommendation concern the application of helpful modern technologies. Depending on the budget and government’s available financial support, these technologies include scanning wristband barcodes, radio frequency identification (RFID), biometric Identification systems, referential matching software, and others. The first variant is one of the most affordable, widespread, and maintained by substantial evidence, while RFID is cost-prohibitive but effective indeed (Riplinger et al., 2020). Besides, laboratories can equip specimens with barcodes linked to the hospital information system (HIS).
  3. The third recommendation is connected with a necessity to improve communication in specific units and between various departments. All staff members and managers should be notified of a particular risk of mix-up, and those nurses who are assigned to risky patients should be informed about all changes. In addition, it is necessary to enhance interdepartmental collaboration, especially between emergency, inpatient, and radiology departments and laboratories, by creating joint workgroups.
  4. The fourth recommendation is about the reporting process and related systems. In this regard, Arabi et al. (2016) offer the implementation of a Comprehensive Management System (CMS) that has demonstrated its efficacy in terms of reporting incidents and the time needed for reporting. Nevertheless, the authors indicate that for a successful system’s realization, the management should form a multidisciplinary report committee, adapt their policies, and perform staff training.
  5. The fifth recommendation relates to personnel’s, patients’, and families’ education about the best practices and collaboration. In particular, the hospital should incorporate in-service training on procedures concerning verifying patients’ personalities into healthcare employees’ continuing professional development. Besides, there is a need to educate patients and their families on the importance of precise patient identification and their active involvement in this procedure.


In summary, the paper has analyzed the scenario from simulation activity, determined its implications for patients and the organization, outlined the patient safety officer’s role, and provided practical recommendations. The scenario includes Kyra Dilley and Virginia Anderson who discuss the similarity between names and birth dates of B. Moore and B.R. Moore. The potential risks are related to procedural errors, wrong blood transfusion, extended hospital stay, and patients’ decreased satisfaction and health, and extra costs. Patient safety officers are responsible for ensuring the delivery of quality healthcare for patients by helping form practices following which errors are prevented. Finally, recommendations are connected with the organization’s policies and procedures, modern technologies, interdepartmental communication, reporting process, education.


About the National Quality Strategy. (2017). The Agency for Healthcare Research and Quality. Web.

Arabi, Y. M., Owais, S. A., Al-Attas, K., Alamry, A., Alzahrani, K., Baig, B., White, D., Deeb, A., Al-Dorzi, H. D., Haddad, S., Tamim, H. M., & Taher, S. (2016). Learning from defects using a comprehensive management system for incident reports in critical care. Anaesthesia and Intensive Care, 44(2), 210-220. Web.

ASHP statement on the role of the medication safety leader. (2014). Best Practices for Hospital & Health-System Pharmacy, 70, 448-52.

Choudhury, L. S. & Vu., C. T. (2020). Patient identification errors: A systems challenge. The Agency for Healthcare Research and Quality. Web.

De Rezende, H. A., Melleiro, M. M., & Shimoda, G. T. (2019). Interventions to reduce patient identification errors in the hospital setting: A systematic review protocol. JBI Evidence Synthesis, 17(1), 37-42. Web.

Khammarnia, M., Kassani, A., & Eslahi, M. (2015). The efficacy of patients’ wristband bar-code on prevention of medical errors: A meta-analysis study. Applied Clinical Informatics, 6(4), 716–727. Web.

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Lippi, G., Chiozza, L., Mattiuzzi, C., & Plebani, M. (2017). Patient and sample identification. Out of the maze?. Journal of Medical Biochemistry, 36(2), 107. Web.

Riplinger, L., Piera-Jiménez, J., & Dooling, J. P. (2020). Patient identification techniques –Approaches, implications, and findings. Yearbook of Medical Informatics, 29(1), 81. Web.

Two patient identifiers – Understanding the requirements. (2021). The Joint Commission. Web.

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