TJC Quick Safety Issue 45 – People, Processes, Heath IT and Patient Identification

PUBLISHED: Oct 8, 2018
Relevant to: All Healthcare Organizations

The Joint Commission (TJC) recently issued Quick Safety Issue 45, addressing people, processes, health IT and accurate patient identification. According to TJC, patient identification is universal and ubiquitous occurring with every patient encounter and therefore the process is also “…fraught with risk for wrong-patient errors.” TJC’s first National Patient Safety Goal, NPSG 01.01.01 addresses patient identification because accurate identification is the cornerstone of safe care.

Health IT (electronic health records, order entry, scheduling systems, etc.) and Automated Identification and Data Capture Technologies (bar codes, biometric scanners) usually contribute to accurate patient identification, but there are instances, when not properly implemented, that these technologies can create challenges and barriers to the patient identification process. In their Quick Safety Issue, TJC states that problems health IT and patient identification include:

  • Entering information into the wrong patient record (having multiple patient records open, side by side, or overlaying patient records).
  • Untangling (i.e., separating) co-mingled patient information.
  • Mistakenly creating duplicate charts.
  • Assigning a test to the wrong patient.”

TJC further explains that accurate patient identification includes three components that use both human process and technology:

  • Accurate information gathering (also called “catching” or “capturing”).
  • Accurate information matching.
  • Display of that information to enhance gathering and matching.

Quick Safety Issue 45 presents multiple safety actions for healthcare organizations to consider to improve the patient identification process, incorporating and balancing human processes and technology. Some of the recommendations include:

  • Include and engage clinicians in the EHR configuration process
    • Focus on limiting distractions during the documentation process in order to prevent identification errors.
  • Implement an “active confirmation process” to match the patient and documentation.
    • Verbal confirmation from the patient, entering the patient’s initials, or matching a patient’s photo in a dialogue box prior to confirming orders or after a period of inactivity are examples of methods for active confirmation.
    • Two identifiers should always be used.
  • Implementing a standardized process for patient identification/capturing patient information, regardless of where registration occurs.
  • Implement a distinct method of newborn identification (see also, StayAlert! Notice published June 25, 2018)
  • Ensure a standardized display (i.e., consistent ordering of name) of patient identifiers across various systems, from the registration system through to the EHR.
  • Ensure that patient name is clearly displayed, electronically, on wristbands, and printouts.
  • Implement systems that can identify and detect identification errors.
  • Implement high-specificity alerts and notifications to help with proper identification. For example, a warning alert for similar patient names.

Follow the link below to read the Quick Safety Issue in its entirety. Included with today’s notice are example policies related to accurate patient identification.

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