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Qual Saf Health Care. 2007 April; 16(2): 160.
PMCID: PMC2653157

Identifying patients in hospital: are more adverse events waiting to happen?

In November 2005, the National Patient Safety Agency (NPSA) published a directive concerning identity bracelets in hospitals, and set a deadline of May 2006 for trusts to comply.1 It outlined that all inpatients should wear identification bracelets unless they do not consent, or there is good clinical reason and a formal risk assessment is undertaken to confirm this.

In June 2006, in a large UK university hospital, we conducted a prospective review of 54 emergency orthopaedic admissions to assess adherence to the recommendations. Data were recorded on the morning after admission.

The presence of an identification bracelet on each patient was recorded, as was the accuracy of identification details written on a white board above each patient's bed. The ability of each patient to identify himself or herself was recorded.

In all, 30 (55%) patients did not have an identification bracelet. None of the patients objected to a bracelet or were deemed clinically unsuitable. Four patients without bracelets were unable to identify themselves.

Also, 26 (48%) patients had no identification details written on the identification white board above their respective beds; 4 (7%) patients had incorrect details—those of the previous bed occupant. One of these patients had no identification bracelet and was unable to identify himself. One patient had a similar but incorrect name on the board.

Errors in patient identification clearly remain a cause for concern. The media take delight in sensationalising such errors.2,3,4

A recent study from a US source showed 3273 cases of wrong‐treatment/wrong‐procedure errors recorded over a 13‐year period5—a proportion of which was owing to failures in identification. Between November 2003 and July 2005, the NPSA received 236 reports of safety incidents and near misses relating to missing or inaccurate identification bracelets.1

Use of bracelets in the US has been improved by empowering phlebotomy staff to refuse to take blood from patients until the identification bracelet is present and accurate—the error rate was reduced from 7.4% to 3% over a 2‐year period.6

No data exist relating to the use of patient identification boards. If accurate, they are useful in facilitating identification; but conversely, if inaccurate, they may cause confusion and magnify the risk of adverse events.

The NPSA has not yet been successful in ensuring that safe practice recommendations for the use of identification bracelets are being adhered to. Inaccurate patient identity boards also pose risks to patient safety.

Footnotes

Competing interests: None.

References

1. National Patient Safety Agency Safer Practice Notice. Wristbands for hospital patients improves safety. Nov 2005.
2. Rosen M. Surgeon operates on wrong patient. St Petersburg Times 11 July 1998
3. Bramson K, Mooney T. Doctor removes ovaries from wrong patient. Providence J 18 Aug 2006
4. Mishra R. Wrong girl gets tonsils taken out. Boston Globe 23 December 2000
5. Seiden S C, Barach P. Wrong‐side/wrong‐site, wrong‐procedure, and wrong‐patient adverse events: are they preventable? Arch Surg 2006. 141931–939.939 [PubMed]
6. Howanitz P J, Renner S W, Walsh M K. Continuous wristband monitoring over 2 years decreases identification errors. A College of American Pathologists Q‐Tracks Study. Arch Pathol Lab Med 2002. 126809–815.815 [PubMed]

Articles from Quality & Safety in Health Care are provided here courtesy of BMJ Publishing Group