The wicked problem of patient misidentification: How could the technological revolution help address patient safety?

As nurses, we are at the frontline of healthcare delivery in all settings; this means we will most likely witness or be involved in clinical practice error due to misidentification at some stage over our careers (Hwang & Park, 2017). It is quite possible that during our nursing career, we will administer the wrong medication to the wrong patient. It may be likely that a patient misidentification error has occurred in our workplace today. As much as we recognise the critical importance and safety mechanism of asking the patient their name, their date of birth and checking their identification band, whilst maintaining the six rights of medication administration, identification mistakes still happen for a multitude of complex and multifactorial reasons. These may include the chaotic, time-pressured nature of a busy healthcare environment; a patient's functional ability and capacity; and the accuracy and clarity of information presented on ID bands along with the ease of access to their physical location on patients (commonly secured on a patient's wrist or ankle). All healthcare systems are required to have robust and correct identification and procedure matching for accreditation (Australian Commission on Safety & Quality in Health Care, 2017). Whilst regular ID band auditing has become commonplace across hospital facilities as a reportable quality performance indicator, there is little evidence that regular auditing reduces potentially catastrophic patient identification errors. Further, average reported compliance for patient ID audits reports normally achieve >90%. Adverse events and errors due to misidentification can have extreme consequences with outcomes ranging from near miss to catastrophic events. Patient misidentification can result in patients having the incorrect diagnosis, being incorrectly treated (including surgical procedures on incorrect patients), receiving the wrong drug and mislabelling of pathology collections. Patient identification is a wicked healthcare problem. Wicked problems are considered complex and without a clear solution (Hutchinson, Daly, Usher, & Jackson, 2015). Wicked problems are difficult to solve—they resist conventional solutions, are considered intractable or novel, occur within volatile dynamic environments and attempts to address these problems often leads to the development of new problems (Hutchinson et al., 2015). Complex, dynamic, busy and under-resourced health systems are a fertile ground for wicked problems, and the problem of patient misidentification is one such problem. There are many critical points during a patient's care trajectory where patient identification is necessary and can be jeopardised. These include patient movement, transfer and handover, diagnosis, medication management (including prescription, medication preparation and administration), infusion and transfusion management (including venepuncture), and when in receipt of medical treatment including surgical procedures, devices and implantation. Take the transfusion process as an example of a high-risk activity. Critical points where accurate patient identification is vital include at least eight key points—sample taking, sample receipt, testing, blood component selection, labelling and collection, prescription and administration. At each of these key points, there is potential for patient misidentification and ensuing error with potentially serious sequelae (Serious Hazards of Transfusion, 2017 SHOT Annual Report, 2018). There are a number of patient-level factors that may increase the risk of patient misidentification. These include those in a critical condition or with severe illness where coma or anaesthesia is experienced, delirium or dementia; communication impairment such as aphasia or lack of a common language; patients receiving cancer treatment; and patients with multiple complex comorbidities and frequent health service utilisation. These (and other) factors can create often challenging clinical scenarios, including situations where patients may have reduced capacity to advocate for themselves, express or verbally identify themselves. A recent survey of 772 registered nurses revealed that nurses regarded patient misidentification as a very rare and unlikely event (Bartlova, Hajduchova, Brabcova, & Tothova, 2015). However, numerous patient safety reports demonstrate otherwise, suggesting the need for education and innovative technological approaches to improve patient safety through enhanced strategies for correct patient identification. Patient identification errors are a major contributor to "never events" in our hospitals. Between November 2003 and July 2005, the UK National Patient Safety Agency received 236 reports of patient safety incidents and near misses related to missing ID bands or ID bands with incorrect information (National Patient Safety Agency, 2005). Further, a recent SHOT Annual Report (2017) describes 115 episodes of error involving incorrect patient identification (Serious Hazards of Transfusion (SHOT) Steering Group 2018). Critically, 75% (n = 86 episodes) of these errors occurred in the clinical areas, as opposed to the laboratory. Clinical patient ID errors include incorrect ID (unique identifier or addressograph label), no identification band present or bedside check not performed. The term "never event" was coined in the early 2000s to describe errors that should never occur in health care. However, uses of the term have extended to include serious, preventable and clearly identifiable adverse events. The early never event list now includes 29 "serious reportable events" that are grouped into seven categories: surgical or procedural events; product or device events; patient protection events; care management events; environmental events; radiologic events; and criminal events (PSNet Patient Safety Network, 2019). Never events may include surgery conducted on the wrong patient, medication or procedural errors. A few international examples include a patient's wrong eye removed, the wrong patient being given a new hip replacement and amputation of the wrong limb. However, patient misidentification is also a never event, as it is a failure of patient protection that can lead to catastrophic outcomes. The reality is that patients can die because they were wrongly identified. "What is your full name and date of birth?" is a simple question, and it is one that saves lives. It is a critical safety check that is drilled into nurses from day one of nurse education, so how do patient identification errors continue to occur? There are a number of contributing causal factors including increased patient acuity; workload; nurse fatigue; lack of knowledge; poor ward practices and culture of patient safety; and lack of implementation of patient identification policy (Thomas & Evans, 2004). There are a number of strategies that can be employed to assist in the minimisation of patient identification error. Strategies include (a) every patient being uniquely identified in an unambiguous manner; (b) identification being consistently maintained through the period of care; (c) every procedure, treatment or medication being uniquely identified in an unambiguous manner; and (d) patient identification being explicitly tied to all requests, medications, procedures and devices that are applied (Australian Commission on Safety & Quality in Health Care, 2008). Over 12 years ago, it was recommended that healthcare settings consider feasible implementation of technological systems to decrease identification errors, yet this is still an area in need of investment (World Health Organisation, 2007). Over the years not changed much has changed in the requirements of design or the level of details that included. Wearing plastic hospital identification wristbands is widely accepted standard practice for patient identification. Minimal data include patients' full name, date of birth and hospital number. Yet, patient identification wristbands remain to be problematic, with a recent 2006 study revealing more than 1 in 10 cases of patients being mismatched to their care were directly related to wristbands. Similarities in standard identifiers (medical record numbers) are an issue for nurses caring for the very young in the NICU, who are at high risk of misidentification errors (Gray et al., 2006). Whilst wristbands are a critical tool, they remain unreliable as a safeguard against misidentification. Patient identification wristbands are a structural concern in health care. There are many critical points in the identification process where failure can occur. Failure can occur when the plan is adequate, but the associated actions do not play out as intended. Reason (1995) defines these failures as failures of execution, whereby slips relate to observable action and are linked with attentional failures (such as the nurse was busy and did not check the ID band before giving the medication). Further, failure can also occur when the actions go entirely as planned (nurse check ID band before giving medication), but the plan was inadequate (the patient may have been provided with the incorrect ID bands) to achieve its intended outcome (safe administration of medication to patient) (Reason, 1995). Improving healthcare culture to greater recognise the importance of patient safety is paramount. Technology may contribute to reducing misidentification errors and improving patient safety. Automated systems such as barcode technology, radiofrequency ID (RFID tags), biometric technologies (such as iris scanning or fingerprinting) and the adoption of smartphone facial recognition technology are all possible solutions that could be implemented, where feasible. There remains significant scope to improve the overall design of patient ID bands to mitigate human factors. Although technology cannot succeed without strong patient safety initiatives such as partnership and engagement of patients, informal caregivers, relatives and family in education on patient safety need to be developed and fostered. Nurses need to be skilled and confident in communicating with patients and their families about the need for good patient identification processes and the risk of misidentification. There is a large delay between the technological revolution, and keeping the most vulnerable members of our communities' safe in healthcare settings. Nurses now respond to a larger number of patients who present to healthcare settings without an advocate. The most commonplace method of patient identification remains a plastic band with an addressograph with perhaps a barcode on a patient's arm, with nurses verbally confirming patient details. Surely, in 2019, there is a safer way to safeguard patients from the harm of misidentification. Let's revolutionise patient identification. If facial recognition allows us to unlock our smartphones, surely it is time such technology is applied to health care, where patients are at their most vulnerable and at risk of potentially catastrophic adverse events.