Open Access Article
Article
Patient Misidentification in Oncology Care
Patients with cancer are at risk for patient misidentification, or "wrong patient" incidents. Patient misidentification can result in medication and transfusion errors, unnecessary testing or procedures, and, in some cases, death. Patients may be misidentified when nurses mispronounce their names, refer to them by their first or last names only, are complacent and fail to check armbands, or encounter language or communication barriers. Errors caused by patient misidentification can be prevented when healthcare providers consistently use two unique patient identifiers (other than the patient's room, examination, or chair number) to verify identities.
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References
Associated Press. (2004). Hospital patient dies after being given wrong blood. St. Petersburg Times. Retrieved August 8, 2007, from http://www.sptimes.com/2004/07/18/State/Hospital_patient_dies.shtml
Bittle, M. J., Charache, P., & Wassilchalk, D. M. (2007). Registration-associated patient misidentification in an academic medical center: Causes and corrections. Joint Commission Journal on Quality and Patient Safety, 33(1), 25-33.
Cochran, G. L., Jones, K. J., Brockman, J., Skinner, A., & Hicks, R. W. (2007). Errors prevented by and associated with bar-code medication administration systems. Joint Commission Journal on Quality and Patient Safety, 33(5), 293-301.
Institute for Safe Medication Practices. (2007). The five rights: A destination without a map (January 25, 2007, ed.). Acute Care Newsletter. Retrieved August 8, 2007, from http://www.ismp.org/Newsletters/acutecare/articles/20070125.asp
Joint Commission. (2006). Medication station. Part I: Identifying risks in the medication use process. Strategies for pharmacists. Joint Commission Perspectives on Patient Safety, 6(1), 3-6.
Joint Commission. (2007). FAQs for the Joint Commission's 2007 national patient safety goals. Retrieved August 8, 2007, from http://www.jointcommission.org/NR/rdonlyres/49313BED-3D00-4740-A5D7-91900A6052A3/0/07_NPSG_FAQs_1.pdf
Joint Commission. (2008). 2008 national patient safety goals. Retrieved August 10, 2007, from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm
Kaplan, H. S. (2005). Getting the right blood to the right patient: The contribution of near-miss event reporting and barrier analysis. Transfusion Clinique et Biologique, 12(5), 380-384.
Lau, F. Y., & Cheng, G. (2001). To err is human nature. Can transfusion errors due to human factors ever be eliminated? Clinica Chimica Acta; International Journal of Clinical Chemistry, 313(12), 59-67.
Li, C., Barreto, A., Chin, C., & Zhai, J. (2006). Biometric identification using 3D face scans. Biomedical Sciences Instrumentation, 42, 320-325.
Mordini, E., & Ottolini, C. (2007). Body identification, biometrics and medicine: Ethical and social considerations. Annalidell'Istituto Superiore di Sanità, 43(1), 51-60.
Murphy, M. F., Casbard, A. C., Ballard, S., Shulman, I. A., Heddie, N., Aubuchon, J. P., et al. (2007). Prevention of Bedside Errors in Transfusion Medicine (PROBE-TM) study: A cluster-randomized, matched-pair clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check. Transfusion, 47(5), 771-780.
Pagliaro, P., & Rebulla, P. (2006). Transfusion recipient identification. Vox Sanguinis, 91(2), 97-101.
Pothen, D. J., & Parmanto, B. (2001). Biometric authentication: Privacy protection or invasion? Journal of AHIMA, 72(7), 24, 26.
Rosenthal, M. M. (2003). Check the wristband. Web M&M: Morbidity and Mortality Rounds on the Web. Retrieved August 10, 2008, from http://webmm.ahrq.gov/case.aspx?caseID=22&searchStr=check+the+armband
Allen, S. (2005). System targets blood-type mix-ups. The Boston Globe. Retrieved August 8, 2007, from http://www.boston.com/news/globe/health_science/articles/2005/02/24/system_targets_blood_type_mix_ups/?page=1