We’ve seen the movies that feature a patient in a hospital who is wrongly informed of a fatal disease and told that they have days or months left to live. The patient then packs their bags and spends all their money on an adventure, only to return and find out that their diagnosis has been mixed up with another patient. While this situation might be popular in the movies, the real-life outcomes of patient mix-ups are much worse.
We know that identifying patients is critical when it comes to patient safety. So critical in fact, that the Joint Commission has made it their first focus in the 2019 National Patient Safety Goals . Though several thousand cases of mistaken patient identity have been reported , it is still the most misunderstood health risk – an outcome that patients do not expect to happen.
In a Mayo Clinic study with the American College of Surgeons , 8.9% of participating US Surgeons reported the belief that they made a major medical error within the previous 3 months of completing the survey – and 1.5% believe that their error resulted in a patient’s death. When we pause and consider the effect on patient and staff lives because of medical errors, it is heartbreaking. Especially considering that these situations could have been avoided by the integration of alerting technology that warns hospital staff when a potential patient mix-up has occurred.
How do we mitigate this?
The best course of action to avoid patient mix-ups is for healthcare providers to focus on integrating technology sooner rather than later, to alert the assigned care team quickly when a patient is at risk of being confused with another patient.
In October 2016 at our annual WorldConnex event, we met with a Certified Biomedical Equipment Technician from one of the leading teaching hospitals and biomedical research facilities in the United States. We discussed the technology that has been integrated in order to reduce patient mix-ups, increase quality of life for hospital staff, and ultimately improve patient safety. This Connexall integration compares data in 2 different systems and alerts the appropriate care team(s) if patient information in each system does not match.
Before Connexall, there were 3 main errors that occurred:
- Patient monitors required a tedious data entry method that had to be done manually. This meant that typos were frequent, fields were left blank and names were shortened to save time.
- Staff had to make a modification to the patient’s ID number before they could enter the MRN in the system. In order to comply with EKG storage system requirements, staff had to convert the original 7-digit number into a 9-digit MRN with no alphabetical characters. This also left lots of room for human error and increased the time it took for clinicians to complete administrative tasks.
- The patient module would retain the previous patient’s information if the staff failed to erase, discharge, or change it. When a new patient was admitted, old patient data could be left in the patient module, which meant that this data could be assigned and confused with a new patient. This was a dangerous problem because it was easy to have the entirely wrong patient connected to data that was not theirs at all.
Something needed to be done in order to mitigate patient mix-ups, improve efficiency and save time.
Solution 1: New ADT Interface
The facility implemented a new ADT interface on the computer monitors; this meant that staff could search for patients by name and select them. This helped to improve efficiency, however, the original problem remained: data could still be left in the patient module which contributed to patient mix-ups. Furthermore, it was now easier to choose the completely wrong patient from the list.
A further solution was still required.
The Connexall Solution: Patient Data Integrity
Connexall engineers and the team at the facility collaborated to develop the patented Connexall Patient Data Integrity Solution. Patient information is recorded from the patient monitor and the ADT, funneled through Connexall and compared. If the patient information does not match, the appropriate party is sent a notification including patient location so that they can take action, eliminating the risk of patient mix-ups.
We are proud to be partnered with a facility that recognizes the importance of this and has actively put solutions in place to improve patient safety.
Here are some other ways that healthcare providers can improve patient safety within facilities:
- Use at least 2 patient identifiers when providing treatment. Note: the patient’s room number and physical location cannot be used as an identifier. 
- Label containers used for blood and other specimens in the presence of the patient. 
- Use distinct methods of identification for newborn patients. For example, use a distinct naming system that includes the mother’s first and last names and the newborn’s sex. 
- Whenever possible, verbally inform the patient’s nurse of new written medication orders. 
- Do not allow patients with similar names to be placed in the same room.