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Patient Safety Tip of the Week
January 24, 2023
Tale
of 2 Graces
Our December 17, 2019 Patient Safety Tip of the Week Tale of Two Tylers showed a healthcare mix-up of a hockey
player and a basketball player, both named Tyler Ennis. X-rays of one Tyler
Ennis were mistaken for those of the other Tyler Ennis. Fortunately, there were
no adverse consequences from the mix-up but there could have been.
While it is not, per se, a patient safety example, a recent
Kaiser Health News story (Kreidler
2022) showed how the same type of patient misidentification can lead
to nightmares for a patient. The snafu involved 31-year-old Grace E. Elliott and
81-year-old Grace A. Elliott. Grace E. had a hospital visit with a small bill 8
years earlier while visiting her parents in Venice, Florida. Grace A. had an
expensive shoulder replacement at the same hospital years later. But a bill
addressed to Grace E. was sent to Grace Es mother with charges for a shoulder
replacement (Grace E. was no longer living in Florida). Initially suspecting
possible identity theft, Grace E. contacted the hospital. After several weeks
and multiple phone calls, the corporate office for the hospital let Grace E.
know of the hospitals error and promised to correct it. But, in the interim,
the account had been turned over to a collection agency and the
misidentification was not communicated to the collection agency. Two appeals to
the collection agency were denied. It was only after involvement of a reporter
that the snafu was ultimately resolved. In all, it took nearly a year of
hours-long phone calls to undo the damage.
In addition to the patient identification error, there were
obviously communication errors. Hospital ownership had changed, and the hospital
had actually closed prior to this case being resolved. Moreover, in one of the
collection agencys denial letters several pages of the older womans medical
information were disclosed (certainly sounds to us like there may be HIPAA
implications). Though the case involves billing records, the latter issue also
raises the question about whether any medical information has been incorrectly
included in the medical records of either or both of these patients.
Correct patient identification is the responsibility of all
hospital personnel, not just clinicians. Two-factor identification is the
minimum requirement. Most hospitals and healthcare facilities use patient name
and date of birth as the two identifiers. Grace E. and Grace A. had different
dates of birth. But even using date of birth may not be an adequate safeguard. In our March 26, 2019 Patient Safety Tip of the Week Patient
Misidentification we noted a near-miss when two patients had
the same name and same date of birth and noted the fact that, in one hospital
district in Texas, 2488 patients were named Maria Garcia, and 231 of these
(9.3%) also shared the same date of birth! (Lippi 2017).
Our December 17, 2019 Patient Safety Tip of the Week Tale of Two Tylers showed a glaring example of how patient
photographs in the EMR might prevent a wrong patient error. Obviously in the
current case photographs could also have easily distinguished patients of
widely different ages.
Our December 17, 2019 Patient Safety Tip of the Week Tale of Two Tylers also has a discussion on how a long-overdue
national patient identifier (NPI) system could serve as a means of preventing
patient misidentification.
We recommend you read the entire Kaiser Health News story (Kreidler
2022) for all the details of the current example. This is an excellent
story you should include in your orientation of non-clinical personnel in your
organization to emphasize the importance of correct patient identification at
all times.
Some of our prior
columns related to patient identification issues:
May 20, 2008 CPOE Unintended Consequences Are Wrong
Patient Errors More Common?
November 17, 2009 Switched
Babies
July 17, 2012 More on Wrong-Patient CPOE
June 26, 2012 Using Patient Photos to Reduce CPOE Errors
April 30, 2013 Photographic
Identification to Prevent Errors
August 2015 Newborn Name Confusion
January 12, 2016 New Resources on Improving Safety of
Healthcare IT
January 19, 2016 Patient Identification in the Spotlight
August 1, 2017 Progress
on Wrong Patient Orders
June 19, 2018 More
EHR-Related Problems
November 2018 More
on Hearing Loss
March 26, 2019 Patient
Misidentification
May 21, 2019 Mixed Message on Number of
Open EMR Records
September 10, 2019 Joint Commission Naming
Standard Leaves a Gap
December 17, 2019 Tale of Two Tylers
March 24, 2020 Mayo Clinic: How to Get
Photos in Your EMR
June 16, 2020 Tracking Technologies
November 17, 2020 A Picture Is Worth a
Thousand Words
August 3, 2021 Obstetric Patients More
At-Risk for Wrong Patient Orders
Some of our prior columns on use of patient photographs
in patient safety:
December 2008 Patient Photographs Improve
Radiologists Performance
January 12, 2010 Patient
Photos in Patient Safety
June 26, 2012 Using Patient Photos to Reduce CPOE Errors
April 30, 2013 Photographic
Identification to Prevent Errors
January 19, 2016 Patient
Identification in the Spotlight
March 26, 2019 Patient
Misidentification
November 12, 2019 Patient Photographs Again
Help Radiologists
December 17, 2019 Tale of Two Tylers
March 24, 2020 Mayo Clinic: How to Get
Photos in Your EMR
November 17, 2020 A Picture Is Worth a
Thousand Words
References:
Kreidler M. The case of the two
Grace Elliotts: A medical billing mystery. Kaiser
Health News 2022; December 21, 2022
https://khn.org/news/article/mistaken-identity-two-grace-elliotts-medical-billing-mystery/
Lippi G, Chiozza L, Mattiuzzi C, Plebani M. Patient
and Sample Identification. Out of the Maze? J Med Biochem
2017; 36(2): 107-112. Published online 2017 Apr 22
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471642/
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