The Importance of Patient Identification

Ensuring that the right patient receives the appropriate care is critical in healthcare.  However, the Pew Charitable Trust and the Ponemon Institute have reported that patient misidentification is a recurring issue, with hospitals reporting significant financial losses in the millions due to denied claims for reimbursement. 

One survey of health-related systems reported that over a third of them spend over one million dollars annually to resolve patient identity issues. This problem, which can occur in any healthcare setting, underscores the urgent need for improved patient identification processes and the adoption of modern, reliable methods such as biometric identification, unique patient identifiers, and barcode scanning that can effectively address this issue. 

As we embark on Patient Identification Week (May 13-17), it is befitting for health information (HI) professionals to support the efforts of the Patient ID Now Coalition and others in raising awareness about patient identification and matching in healthcare. This is not a problem without a solution. With our expertise and knowledge, we are well-positioned to assist healthcare systems and legislators in identifying and implementing practical solutions to address patient misidentification, bringing about a future where patient identification is accurate and reliable. 

The Negative Results of Patient Misidentification

Problems caused by misidentification include misdiagnosis, documenting in the wrong chart, claims denials, and even death. Matching individuals to their medical data can be challenging due to spelling errors, changes in residency, and married and maiden names, among many other issues. Not taking the necessary precautions at registration or intake is the number one cause of patient misidentification. 

A 2019 study identified additional points of contact where patient information could be compromised, including patient movement between clinical areas during their health encounter, transferring between care facilities, medication distribution, before surgical procedures, or during the transfusion process. 

In an investigation of common errors in administering chemotherapy treatment, it was found that 14 percent of 140 reported chemotherapy errors involved patient identification.  Researchers retrospectively reviewed the Veteran Health Administration’s national patient safety event reporting and root cause analysis (RCA) databases from October 1, 2016, to September 30, 2018, for inpatient, outpatient, and administrative settings. They discovered misidentification was common in their inpatient and outpatient settings, citing not following protocols as the most common cause. 

Using the electronic medical record database of one neonatal intensive care unit (NICU), clinicians found that each day of care was at risk for misidentification during a one-year study reviewing 12,186 days of patient care for 1,260 babies. Similar-looking medical record numbers (MRNs) accounted for 44 percent of patient days, the most frequent cause of misidentification risk. When multiple births were excluded from the analysis, the percentage decreased to 26.4 percent for similar MRNs.

Best Practices

Some recommended best practices to minimize the chances of misidentification include implementing processes for collaboration and communication between key departments, consistent training, quality controls, creating a data integrity team to monitor real-time opportunities for misidentification, and reporting findings and recommendations to key stakeholders. Using technology, such as scanners and barcodes, when verifying patient information has also decreased the risk of misidentification at the bedside, according to a 2016 AHIMA workgroup.

In January 2021, the Patient ID Now coalition formed a workgroup of member organizations representing patients, physicians, providers, HI professionals, HI technology companies, and public health to create a comprehensive framework for a national strategy around patient identity. The framework included strategies for accurate identification, addressing privacy and security issues, standardization, equitability and inclusion, sustainability and governance, portability and inoperability, integration, and data quality.

In February 2024, Representative Mike Kelly (R-PA) and Representative Bill Foster (D-IL) in the US House of Representatives introduced the Patient Matching and Transparency in Certified Health IT (Match IT) Act of 2024. It addresses the problem of patient misidentification, improves patient safety and privacy, and improves standardization of patients’ demographic elements — to allow measurement of patient match rates across the healthcare system by creating an industry standard definition for the term “patient match rate.”

Let us support these efforts at the local level where the most significant impact can occur.  Be involved in creating policies and processes for minimizing patient misidentification, stress the importance of allocating resources with your organization’s leaders, and advocate in your community and encourage your local, state, and federal legislators to support legislation that sets national standards to improve patient identification.  Together, we can make a difference and create change.

Mona Calhoun, PhD, MS, MEd, RHIA, FAHIMA, is the president/chair of the AHIMA Board of Directors.