Patient Mixups a Recipe for Disaster

Patient Mixups a Recipe for Disaster

mixing up patient recordsThe patient's doctor delivered the bad news: A CT scan showed cancer. Surprisingly, though, just two months later a biopsy failed to detect a malignancy, leading a puzzled doctor to order a second biopsy. The mystery was solved when a radiologist discovered that the initial CT scan that revealed the cancer actually belonged to a different patient it was a case of mistaken identity. Boston Globe 2016

Wrong-patient, wrong-site, and wrong-procedure errors are all considered never events by the National Quality Forum, and are considered sentinel events by The Joint Commission. In February 2009, the Centers for Medicare and Medicaid Services (CMS) announced that hospitals will not be reimbursed for any costs associated with "wrong-site, wrong-procedure, wrong-patient errors".

The practice of having a patient identify themselves adequately is vital in providing the correct care for each individual. Historically the failure to correctly identify patients in the healthcare industry has resulted in medication errors, written and oral communication errors, testing errors, and even procedures conducted on the wrong person.

TRAINING UPDATE: New HIPAA Privacy Slide: Standards of Practice for Patient Identification

We have recently augmented the HIPAA Privacy Training to include Standards of Practice for Patient Identification. This slide will train your staff members on best practices for patient identification. You can also further customize this slide with additional procedures employed in your particular organization. Here is the slide content:


The use of multiple patient identifiers improves the reliability of the patient identification process and decreases the chance of incorrect procedures, physical exams and consultations. The use of multiple patient identifiers is also considered a best practice in the instances where patient names have the same or similar spelling and/or pronunciation.

Examples of acceptable patient identifiers include:

A. Name
B. Assigned identification number
C. Telephone number
D. Date of birth
E. Social security number
F. Address
G. Photograph

The following are recommended instances for verification of patient identity:

1. When a procedure or appointment is scheduled
2. When the patient presents at the healthcare facility registration desk and when handing out patient paperwork
3. At patient Discharge and Checkout
4. Prior to sending out billing or patient correspondence through mail
5. When writing or filling prescriptions
6. When you are calling to speak to a patient about their healthcare
7. Prior to sedation or treatment
8. Anytime the patient is transferred to another caregiver
9. Prior to the patients' entry into an operating room, radiology suite or other area of the facility for any invasive exam

If you have any questions or would like more information about how we can help your organization ensure compliance with HIPAA Privacy and Security, please feel free to contact us by phone: 855-427-0427 or by email:[email protected].