2034. Patient Misidentification in the VHA
Dea M Mannos, MPH, VHA National Center for Patient Safety, EJ Stalhandske, VHA National Center for Patient Safety, SD McKnight,
VHA National Center for Patient Safety, JP Bagian,
VHA National Center for Patient Safety
Objectives: To analyze and monitor patient misidentification events reported to the National Center for Patient Safety (NCPS) in order to provide useful and current information to teams seeking to correct the vulnerability at VA facilities.
Methods: NCPS database that stores root cause analysis (RCA) reports was searched using Natural Language Process (NLP) techniques. Weekly lists of newly submitted RCAs are systematically reviewed for misidentification events. All relevant RCAs are categorized for event type, severity, and location.
Results: From 01/2000 to 05/2003, 138 patient misidentification events were reported to NCPS. These reports cover 36 states and 66 facilities with an average of 3.8 reports per state. Twenty-five percent of total reports involve misidentification and transfusion. Twenty-one percent involve misidentification and invasive procedures. The majority of reports (65%) indicated the patient was unharmed or without permanent physical injury. Two resulted in patient death. Forty-six percent of reports cited three root causes of the event and a total of 659 actions have been proposed by facilities to address patient misidentification.
Conclusions: Misidentification occurs in many areas of the VA hospital, involves a variety of process, and does so with regularity. The consequences can go beyond direct harm to the immediate patient. VA hospitals have taken steps to reduce future incidences of patient misidentification and, their efforts should not go unnoticed.
Impact: NCPS is currently working to create outcome measures to evaluate the success of selected actions. Over time, the results of such outcome measurement will contribute greatly to our knowledge of patient safety practices.