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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 E’s 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 hospital’s 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 agency’s denial letters several pages of the older woman’s 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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