Problem Addressed

Although not common, patients occasionally are misidentified and consequently receive care intended for another individual. In a substantial number of these cases, the error stems from orders being entered into the wrong patient's chart, a problem that may be exacerbated by use of electronic records (EHRs).

• Incorrect care due to patient misidentification: Patients occasionally receive care intended for someone else because they have been mistaken for another patient. Recognizing this problem, the Joint Commission called for the use of two patient identifiers before the provision of any care, treatment, or service to a patient; it designated this practice its first National Patient Safety Goal.²
• Orders entered into wrong chart: Although multiple factors contribute to patient misidentification and subsequent errors, entering orders into the wrong patient chart plays a significant role. One study, for example, found that clinical notes meant for one patient ended up in a different patient's EMR between 0.3 and 0.5 percent of the time.³Although an infrequent occurrence, these mistakes can result in a meaningful number of patients receiving care intended for someone else. At Children's Hospital Colorado, nearly one-fourth (12 of 51) of cases in which patients received inappropriate care due to patient misidentification resulted from a medication or test order being placed in the wrong chart. This figure, moreover, significantly underestimates the magnitude of the problem, as there were also 33 “near misses” in which incorrectly placed orders were caught, questioned, and corrected by nurses or pharmacists before the order was filled.⁴
• Potential new sources of human error with electronic systems: EHRs and electronic systems introduce new ways in which orders can be entered into the wrong chart. Physicians may inadvertently open the wrong chart by clicking on the incorrect name in a long, electronic list of patients. Similarly, most EHR systems allow clinicians to have multiple charts open simultaneously, making it possible to mistakenly enter an order into the wrong chart.

Description of the Innovative Activity

Children's Hospital Colorado requires clinicians in both the inpatient and outpatient setting to confirm all orders entered into the computerized order entry system through a popup verification screen that includes a prominent photograph of the patient, along with other key information such as age and gender. The goal is to capture the clinician's attention and assist him or her as they then affirmatively verify that the order has been entered into the correct patient's chart. Key program elements are outlined below:

• Taking photograph, uploading to medical record: Whenever a new patient goes through the registration or admission process at any hospital-affiliated facility, staff request permission to take a picture of the patient to be included in the medical record, explaining that the photograph will reduce the risk of misidentification and related errors. Staff ask existing patients who already have a photograph in the system to take a new photograph if sufficient time has passed since the last photograph (a year or more), or the patient's appearance has changed meaningfully. Assuming the patient agrees (the vast majority do), staff take the picture with a digital camera that automatically uploads it into the medical record. The equipment has also been placed on most inpatient units, so that unit staff can take pictures of those directly admitted to the unit (without going through the normal registration or admission process). On any given day, roughly 95 percent of patients have a photograph in their medical record. Of those who do not, most have refused to have their picture taken, although in very rare cases staff forget to take the picture.
• Verification screen with prominent photograph: Whenever a provider enters and prepares to sign an order, a popup screen appears with a prominent photograph of the patient and other key identifying information, including name, gender, and date of birth. This verification is also featured on Epic’s provider based mobile application, Haiku. Providers report that the screen gets their attention, particularly when the child in the photograph is not the one they expect to see. At the top of the screen right above the photograph and patient information, the text reads “To continue signing this order, verify the patient is correct.”
• Order confirmation: After looking at the photograph and other information, the provider clicks either the “yes” button to confirm the order or the “no” button to cancel it. The provider must click the “accept” button to execute the order or the cancel button to retract the order.

Context of the Innovation

A 575 bed teaching hospital, Children's Hospital Colorado handles roughly 16,000 admissions, 10,000 observation cases, 600,000 outpatient visits, and 160000 emergency department/urgent care visits each year. The hospital has a single EHR throughout all of its facilities and since 2007 has used the system for all provider order entry and clinical documentation. The EHR is also used by 8 affiliated primary care pediatric practices with 64 providers.

The impetus for this program came in 2009, when organizational leaders responded to a number of errors and near misses caused by patient misidentification that were reported through the hospital's voluntary reporting system. These reports convinced organizational leaders of the need to make reducing these errors a top priority for 2010. At the same time, these leaders engaged in a major effort to encourage staff to report any and all errors and near misses specifically related to patient identification problems, with the hope that such information would provide both baseline data on the magnitude of the problem along with information that could be used to determine root causes and potential solutions.

Patient misidentification is not a problem unique to Children’s Hospital Colorado. In 2016, a survey of 503 nurses, physicians, IT practitioners, and CFOs/financial operations experts found that 86 percent of respondents have witnessed or known of a medical error resulting from patient misidentification. According to 63 percent of respondents, incorrect identification of patients at registration is the primary root cause.⁵

Results

The program has significantly reduced cases in which patients receive or nearly receive care intended for someone else as a result of an order being placed in the wrong chart. This reduction has been the major driver of an overall decline in patient identification errors from all causes. A review of 2019 data demonstrates that other than labeling mishaps resulting in repeat blood draws, the system has not identified serious harm or had reports of wrong care delivered to an incorrect patient due to not following good patient identification practice.

• Fewer errors, near misses due to order placed in wrong chart due to order verification: In 2011, 3 patients received care intended for someone else because of orders being placed in the wrong chart, down 75 percent from the 12 patients who were impacted by this type of error in 2010. A similar decline occurred in near misses (patients who would have received care intended for someone else if staff had not intervened), which fell from 33 in 2010 to 12 in 2011.⁴
• Even fewer errors when photograph in place: Because the system for taking and incorporating photographs was not fully implemented until the end of 2011, not all patients that year had their photograph incorporated into the medical record. Among patients who did, the decline in errors and near misses was even more substantial—in fact, no patient with a photograph in place was reported to have experienced this type of error in 2011, while only one of ten patients reported to have near misses (order placed in wrong chart but error identified and order not completed) had a photograph in the record as compared with nine who did not. In other words, the program virtually eliminated this type of error and near misses in patients with a photograph in their chart and the order verification step in place. One such error was reported in early 2012, marking the first time a patient with a photograph in place was reported to have received care intended for someone else because of a misplaced order in more than 450 days.⁴
• Major contributor to decline in all identification-related errors: For the hospital as a whole, reports of care being provided to an incorrect patient fell by 25 percent between 2010 and 2011, from 51 to 37. The bulk of this decline is attributable to this program, since the prevalence of identification-related errors due to other causes (e.g., failure to match medications to the patient at the point of care) did not change significantly over this time period.⁴

Planning and Development Process

Key steps included the following:

• Forming project team: In mid-2009, a project team formed to take charge of efforts to reduce errors caused by patient misidentification, including but not limited to those that stem from entry of orders into the incorrect chart. The team consisted of physicians, nurses, administrative leaders, quality and patient safety staff, and representatives from clinical and ancillary departments across the organization, including information technology (IT) and clinical informatics. Two family member representatives also participated, bringing the patient perspective to the team.
• Analyzing errors: A member of the project team reviewed and categorized every reported error or near miss thought to be associated with patient misidentification.
• Meeting weekly with core group: A core group of project team members met on a weekly basis to review data and coordinate and oversee implementation of various initiatives designed to reduce identification-related errors, including changing hospital policies, auditing the presence and use of patient wrist bands, changing staff practices related to wrist bands, educating staff about best practices, and encouraging the reporting of errors and near misses so as to identify systemic risks and opportunities to address them.
• Identifying incorrect order placement as major driver: After 6 months, it became clear that placement of orders or clinical information in the wrong electronic chart accounted for a sizable part of the problem. Although this problem had not been prominent in the team's initial literature review, a subsequent review identified two studies that highlighted it—one study found that providers generally miss patient identification errors during computerized order entry and seldom verify identification before ordering,⁶ and a second study found that clinical notes are occasionally placed in the wrong electronic record, and that these mistakes are seldom corrected.³
• Redoubling efforts at identified problem: The project team established an explicit goal to reduce the frequency of errors caused by placement of orders in the wrong chart. The team worked with IT staff to identify potential strategies to address the problem.
• Choosing specific strategy: The team and IT staff generated a number of potential strategies to address the problem, including limiting the number of records a provider can have open at the same time. After further deliberation, they decided not to pursue this strategy, as they had no direct evidence that having multiple charts open simultaneously was a major contributing factor, and staff expressed concern about the time requirements and workflow disruptions that such a policy would entail. Instead, the team decided to pursue creation of an order verification screen with a prominent photograph of the patient.
• Designing verification screen: Over a period of several months, IT staff worked with clinicians to design and create the order verification screen, which included prominent placement of the picture.
• Implementing in phases across organization: Throughout 2011, the hospital installed digital cameras and put in place processes to take and capture patient photographs, with the system being deployed across all inpatient and outpatient departments by the end of the year. Implementation began in the inpatient setting and then transitioned to outpatient facilities, with ambulatory departments where leaders and staff strongly supported the program generally implementing it earlier and those more skeptical adopting it later, after it had been shown to work.

Educating and training staff: The Director of Patient Access served as the point person for staff education and training. This individual attended staff meetings to explain the purpose of the program and to teach frontline staff how to explain to patients why their picture was being taken and how to incorporate the picture-taking process into existing workflows.

Resources Used and Skills Needed

• Staffing: The program required no new hiring, as all upfront planning and ongoing program-related activities occur as part of regular staff duties. During the upfront planning phase, roughly 8 to 10 staff participated in the core patient identification team over a period of approximately 18 months, including 6 to 9 months spent analyzing the problem and creating the program, followed by 9 to 12 months of phased implementation. On an ongoing basis, approximately 50 registration, admissions, and unit-based staff take pictures of patients as part of their regular duties.
• Costs: Costs included the purchasing of a few hundred digital cameras at approximately $90 each, totaling roughly $20,000. Program developers did not quantify the cost of staff time to implement the system versus the cost of staff time associated with fixing medical records where data has been entered incorrectly or responding to errors.

Funding Sources

Children's Hospital Colorado funded this program internally.

Getting Started with This Innovation

Getting Started with This Innovation

• Refine and expand program over time: The project team should evaluate the success of the early, small-scale tests, making changes as necessary to address problems. Early successes can be used to encourage expansion to other departments, beginning first with departments in which leaders and staff support the concept. Once the program has been shown to work in multiple departments, initial skeptics will likely embrace it.
• Monitor and share data on program impact: As part of its regular safety reports, Children's Hospital Colorado tracks the number of patient misidentification errors and the root causes of these errors, including placement of orders in the wrong chart. Regularly seeing the program's positive impact on the frequency of such errors encourages staff to maintain compliance with the picture-taking process. Over time, the new process has become the accepted way of doing business, with few if any staff considering going back to the “old way.”
• Update photographs as necessary: A patient's appearance changes over time, particularly with children. Consequently, organizations need to update photographs for young patients at least once a year and perhaps more frequently if staff members notice a change in appearance. Photographs of adult patients can be updated less frequently.

Sustaining This Innovation

Sustaining This Innovation

• Establish organization-level goals that include incentives for employees and leadership: Leadership ensured that decreasing patient misidentification was a “top level” organizational goal and had hospital-wide visibility regarding how patient identification practices were improving.
• Encourage discussion of near misses: Leadership promoted regular discussion and transparent sharing of data related to near misses or instances of patient misidentification to enable shared learning and alleviate the risk of mistakes in the future.
• Invest in technology advancements: Since this innovation was first implemented, there have been a multitude of advances in technology associated with patient identification and facial recognition. Continuous investment in the equipment to both improve the images in the medical record and to improve the overarching process can support continued sustainment of the program. For example, Children’s Hospital Colorado found that incorporating the use of bar coding along with the placement of pictures in the medical record and verification screens in the ordering process was essential to a successful process. 

References/Related Articles

Hyman D, Laire M, Redmond D, et al. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics. 2012;130:e211-9. [PubMed]

Footnotes

[1] Stanford Medicine News Center. Say cheese: Patient photos being added to medical record. Available at: https://med.stanford.edu/news/all-news/2014/03/say-cheese-patient-photos-being-added-to-medical-record.html.

[2] The Joint Commission. National patient safety goals: hospital accreditation program. Available at: http://www.jointcommission.org/standards_information/npsgs.aspx.

[3] Wilcox AB, Chen YH, Hripsack G. Minimizing electronic health record patient-note mismatches. J Am Med Inform Assoc. 2011;18:511-4. [PubMed]

[4] Hyman D, Laire M, Redmond D, et al. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics. 2012;130:e211-9. [PubMed]

Original Publication

April 9, 2014

Date Verified by Innovator

June 12, 2020