Crozer-Keystone Health System has made it a priority for staff and physicians to ensure that two patient identifiers are used when providing patient care (whether it is direct or indirect care). This is not a new policy, but ongoing education.  Heightened awareness of this policy is critical to ensure that we continue to practice medicine with this as a top priority. It would seem like a simple task to ensure two patient identifiers are used for every interaction with or about a patient. But the literature proves otherwise.

Any number of problems can arise because the patient was not identified accurately.  Medication errors, wrong surgeries, wrong radiology studies, wrong discharge instructions, improperly taking/giving blood and blood products and other specimens for clinical testing, to name a few,  can occur as a result of not properly identifying a patient. If a patient is misidentified and the wrong bracelet is placed on a patient, the error may not be picked up immediately. Unfortunately, serious consequences can arise as a result of not properly identifying the right patient.

Misidentification is something that is not isolated to one care giver or one discipline.  Additionally, it is not isolated to inpatients or to patients that are not competent. What often happens is there is a trust by another care giver during the hand off that the correct patient identifiers were reviewed and the information presented, whether it is the bracelet, name plate, medical record, or patient, is accurate. The bottom line is: trust no one. It is your responsibility to confirm personally that you have the right patient or right patient information by confirming two patient identifiers prior to doing anything. 

At CKHS the two identifiers are patient name and date of birth. If it is necessary to have a third identifier, then the patient’s medical record can and should also be used.

When confirming two patient identifiers with patients, it is not enough to provide the information and have the patient confirm. You must ask the patient to identify themselves/provide the patient identifiers. There have been scenarios where patients presenting for an outpatient study have confirmed the wrong name or birth date. There are numerous reasons for this: patient can’t hear, patient is distracted and didn’t pay attention, patient is in a hurry and answered to anything just to get the given procedure started. Additionally, staff is being asked to have the patient read and confirm his/her name bracelet prior to placing it on the patient.

The two patient identifiers provided by the patient should be confirmed against any and all documents being used in patient care, bracelet, medical record, name plate, medication labels, orders, and reports created. For example, when reviewing x-ray films, both the film and the report form should contain two patient identifiers and the documents should be reviewed to ensure that the film being read is reported to the right patient. Each and every hand off should include confirmation of two identifiers for the patient and paperwork being transported with the patient.

It is everyone’s responsibility to ensure patient safety. Patient identification is the most basic activity and while it may feel redundant, it is necessary 100% of the time to avoid any medical errors. By asking the patient to provide two patient identifiers for confirmation, it actively reinforces to the patient that you are committed to patient safety.