Patient Identification and Adverse Events
Healthcare facilities are facing growing demand for care, with resources stretched thin, exposing patients and healthcare professionals to various risks, particularly the risk of patient identification errors. However, accurate patient identification is a key factor in ensuring their safety throughout their healthcare journey.
Users, as well as healthcare professionals, are not always aware of the risks posed by incomplete identification. Indeed, in the healthcare pathway, the moments when a patient is identified generally take the form of a simple conversation: check-in at the emergency room or admissions department, check-in at the operating room, etc. These moments may seem insignificant, yet they are critical. This often-overlooked criticality is an additional risk factor for patient identification errors. Let’s look at some examples from the Patient Safety Database or the press to illustrate: Ms. and Mr. X are admitted to the emergency room following a traffic accident. They each require a blood transfusion. Ms. X mistakenly receives the blood products intended for Mr. X. A patient admitted to the emergency room for headaches, registered under the wrong name, dies of meningitis because she was unable to respond when her name was called (which was incorrect). (Patient dies at Lariboisière Hospital: investigation confirms malfunctions in the emergency room) A posthectomy was performed on a child admitted to the operating room for a tonsillectomy, following an identification error during transport to the operating room. Incorrect identification can also lead to other adverse events: delayed treatment, diagnostic error, therapeutic error, exchange of erroneous information between professionals, recording of health data in a file that does not belong to the patient concerned (collision), creation of multiple files for the same user, or even a billing error.*
To improve patient safety, the identification process has become a key component of national health policies.
Since January 1, 2021, it has been essential for all healthcare professionals who share data about a patient to identify that patient in the same way. Consequently, the requirement to use the National Health Identifier (INS) has been implemented, reinforcing the principle of patient identification accuracy.
Patient Identification Vigilance: An Institutional Commitment!
Accurate patient identification is the first step in a process that continues throughout their care by the various healthcare professionals involved.
With this in mind, the principle of patient identification vigilance has been strengthened in recent years. Thus, the Ministry of Health and Solidarity defines patient identification vigilance as a set of measures implemented to ensure the reliability of patient identification and the security of their health data at all stages of their care. Patient identification vigilance involves all stakeholders understanding and adhering to identification rules, as well as managing risks related to errors that may occur. Therefore, all healthcare professionals, regardless of their specialty, location, or practice setting, must now follow best practices for identification in order to ensure the secure sharing of health information and to guarantee patient safety. The French National Authority for Health (HAS) had already defined the criterion "Patient identification at all stages of their care" in its previous V2010 and V2014 certifications as a priority required practice. In summary, to guarantee patient safety and avoid adverse events, healthcare professionals must be trained in these reliability measures to enable patient identification at all stages of the care process, before any decision or care procedure concerning the patient.
The SafeTeam Academy and the principle of vigilance in patient identification
The SafeTeam Academy has made patient identification a recurring theme in each of its video simulations, whether they focus on patient well-being in nursing homes, imaging procedures, or surgical procedures. These modules were designed to support healthcare professionals and provide them with the necessary tools to ensure reliable care, particularly with regard to patient identification. These modules prompt healthcare professionals to reflect on their practices and encourage them to constantly verify patient identity through immersive videos depicting simulated care situations. The concept of patient identification can also be applied to healthcare professionals to improve the patient experience. We will return to this topic in another article, dedicated to personalized caps, also discussed by the postman's children (Human Factors in Health).
A humorous clinical case to wrap things up
To wrap up this article with a touch of humor and a reminder to stay vigilant about patient identification, we invite you to watch the following animated clinical case, based on data from the Patient Safety Database.
If you would also like to help improve the quality of care at your facilities, choose SafeTeam Academy training and contact us at contact@safeteam.academy to learn more.
*https://esante.gouv.fr/sites/default/files/media_entity/documents/RNIV%201%20Principes%20communs_1.pdf
