Patient photographs are potential tools in patient safety that have attracted surprisingly little attention to date. In our July 28, 2009 Patient Safety Tip of the Week “” we briefly mentioned using photographs of patients when broadcasting an alert for a missing patient. We recommend that you include in your IT system a digital photograph of patients you identify as being at risk for wandering and elopement. Many communities, often in conjunction with their local chapter of the Alzheimer Association, have programs where families provide photos of their relatives with Alzheimer’s Disease or other dementia to the local police department to facilitate searches when such individuals go missing.
We’ve often thought that inclusion of patient photographs would be a logical tool to use in avoiding wrong patient surgeries or mixups in medication administration. And we were surprised to see that many hospital electronic medical record programs lacked standardized fields for such photographs.
In fact, there are programs that have used patient photographs to reduce the risk of patient misidentification during medication administration (AHRQ Health Care Innovations Exchange). The JPS Health Network in Fort Worth, Texas implemented such a system on its psychiatry units. They first implemented it on adolescent psychiatry in 2000 then, based on success of that program, extended it to their adult psychiatry service in 2006. They noted that this additional method of correct patient identification is especially needed on psychiatry because patients frequently remove their wristband identifications and may be unable or unwilling to respond to questions at the time of medication administration. In the year after implementation on the adult unit, there were no misidentification errors on either unit. Reappearance of misidentification errors a year later led to a reeducation effort and such errors again fell to almost zero.
The AHRQ document nicely describes how JPS went about implementing the program. The resources needed for the program basically amount to a few digital cameras and some staff training. The cameras should be easy-to-use digital cameras. Nurses take a digital photograph of each patient at the time of admission and print one copy for the chart and a second for a 3x5 inch index card that includes the patient label (with patient’s name, date of birth, medical record number, and barcode). That index card then gets clipped to the patient’s MAR (medication administration record). Nurses then use the photograph as a second means of identifying the patient during medication administration (or other nursing activities). The first means of patient identification remains the more standard multiple-identifier method (they use verifying the patient’s name, date of birth and match on the barcode). Other healthcare workers, including physicians and phlebotomists, also use the photographs for patient identification.
On admission, the nurse taking the photograph explains to the patient the reason for the photography (i.e. to avoid patient misidentification) and assures them it will only be used for that purpose. The process is simple and inexpensive and has become a routine part of the admission process on the psychiatry units at JPS.
There are, of course, other advantages to using patient photographs in healthcare (aside from those that are used for clinical activities such as tracking wound healing, etc.). In our December 2008 What’s New in the Patient Safety World “Patient Photographs Improve Radiologists’ Performance” we noted a paper presented at the Radiological Society of North America’s annual meeting showing that inclusion of photographs of patients improved accuracy of radiologists’ reports. Putting a photograph of the patient aside their images on a PAC screen resulted not only in the radiologists feeling more empathy toward the patient but they also identified more incidental findings (the files were chosen because of incidental findings in this randomized study) without taking more time to review the images.
The American Association for Clinical Chemistry (AACC April 2009) reports some healthcare organizations are attaching patient photos to requisitions for Pap smears or other specimens that are being examined.
We think adding patient photographs to electronic medical records (EMR’s) could significantly improve patient safety in other ways as well. They might help prevent a physician from inadvertently ordering on the wrong patient during CPOE. In our May 20, 2008 Patient Safety Tip of the Week “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?” we noted that many orders are now entered into CPOE from remote locations. Having a photograph of the patient at the top of each screen logically should help alert a physician that he/she may be entering that order on the wrong patient.
Patient photographs might also be used on patient identification cards issued by a healthcare system. This might help avoid “medical identify theft” or other fraudulent use of identification. Also, you’d be surprised at how issuing identity cards for your health system fosters loyalty to your system. We recall many years ago when our health system stopped issuing patient cards. The patients complained! They liked having them to carry around. It gave them a measure of security and sense of belonging. So don’t underestimate the potential value of such cards.
But are there downsides to using patient photographs? Though we have been unable to find any good examples in the literature (probably because of the paucity of any literature on use of patient photographs for patient safety), we can certainly anticipate there might be unintended consequences. Just like many other examples we have seen, it could happen that photographs of two patients get mixed up. For example, one might anticipate two patients being admitted around the same time. Each would get photographed. It is conceivable that someone might print out both photographs and erroneously transpose them into the charts or IT system. That is one reason you should never do anything intended for more than one patient simultaneously.
And what about those patients (eg. trauma patients) whose faces may not be recognizeable on admission? And all those babies in the nursery look the same to me! And some patients, particularly those with long stays, may have considerable changes in appearance over time.
And how do you ensure that your staff actually use the photos to aid in patient identification? In a FMEA performed at one institution (Skibinski et al 2007) it was found that in those patients with a wristband present and checked, a second form of patient verification (photograph, verification of birthdate, positive response to stated name, etc.) was not checked 30% of the time. So not only is training and reinforcement necessary but some audit function would be appropriate.
And one must protect patient photographs just as we protect any protected health information (PHI) in any healthcare system. That means strict HIPAA adherence and good auditing trails. You also need to check with your legal counsel locally to ensure that use of patient photos is compatible with all statutes and laws in your state.
We think that use of patient photos has tremendous potential to improve patient safety. But the logisitics, legal and privacy issues, measurable outcomes, and unintended consequences remain to be determined. We’d be interested to hear from any of you how you are using patient photos and whether you have encountered any unintended consequences.
AHRQ Health Care. Innovations Exchange. Innovation Profile: Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification.
AACC. Clinical Laboratory News. April 2009. Patient Safety Focus: Disconnection from Patients and Care Providers
Disconnection from Patients and Care Providers
A Latent Error in Pathology and Laboratory Medicine
An Interview with Stephen Raab, MD
Skibinski KA, White BA, Lin LI, et al. Effects of technological interventions on the safety of a medication-use system. Am. J. Health Syst. Pharm., Jan 2007; 64: 90 – 96