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Jt Comm J Qual Patient Saf. 2007 Jan;33(1):25-33.

Registration-associated patient misidentification in an academic medical center: causes and corrections.

Author information

1
Johns Hopkins University School of Medicine, Baltimore, USA. mbittle@jhmi.edu

Abstract

BACKGROUND:

Proper patient identification is a major factor affecting patient safety in any health care organization.

METHODS:

An interdisciplinary team, using three Plan-Do-Study-Act (PDSA) cycles, reviewed the incidence of patient misidentifications resulting from registration process errors. Retrospective and prospective data were collected to determine the incidence among inpatients and outpatients.

RESULTS:

Registration-associated patient misidentification errors occurred 7 to 15 times per month. Information systems deficiencies, inadequate training, and the lack of a single master patient index were among the root causes identified. After three PDSA cycles, the incidence rate for registration-associated patient misidentification errors declined for inpatients (80.5%) but increased for outpatients (30.2%).

DISCUSSION:

Through an iterative process as implied in the PDSA cycle, registration-associated patient misidentification errors for established Johns Hopkins Hospital patients were dramatically reduced. A checklist is provided for other organizations to assess their vulnerability to registration-associated patient misidentification errors. The checklist suggests, for example, that organizations strive to develop a single master patient index and limit access to registration systems to staff with proper training and performance expectations.

PMID:
17283939
DOI:
10.1016/s1553-7250(07)33004-3
[Indexed for MEDLINE]

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