Wrong-patient errors (WPE) can have deadly consequences and can happen almost anywhere in the healthcare process, including patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, and patient monitoring.
“WPE includes any situation in which a patient is identified incorrectly, regardless of whether the error translates into patient harm,” said Michael J. Brenner, MD, associate professor in the department of otolaryngology–head and neck surgery at the University of Michigan School of Medicine in Ann Arbor. “I emphasize ‘regardless of harm’ because the vast majority are caught before an injury occurs. However, when significant errors do occur, they can result in death or irreparable injury. At the very least, WPEs profoundly impact on a patient’s trust in our system.”
A recent publication from the ECRI Institute, a nonprofit research organization focused on improving patient care, compiled incident reports documenting 7,631 events from 181 healthcare organizations. Researchers noted that 72.3% of errors occurred during patient encounters and 12.6% at intake; additional findings included the fact that 91.4% of errors were found and corrected before any patient harm occurred (ECRI Institute. PSO Deep Dive: Patient Identification: Executive Summary.).
There is, however, little research on the incidence of WPEs in otolaryngology. In 2014, Rahul K. Shah, MD, MBA, a professor of otolaryngology and pediatrics at George Washington University School of Medicine and Health Sciences and vice president and chief quality and safety officer at the Children’s National Health System in Washington, D.C., and his colleagues surveyed members of the American Academy of Otolaryngology–Head and Neck Surgery (AAO–HNS). Of the 681 responders, 445 (66%) reported an event that shouldn’t have happened in the prior six months, from which 222 reports were extracted. The investigators identified adverse consequences in half of the events; corrective actions were reported in 82.8%. Practice pattern changes were instituted 68% of the time (Otolaryngol Head Neck Surg. 2014;150:779–784).
Dr. Shah also said that otolaryngologists are especially vulnerable to WPEs due to the wide variety of settings in which they see patients.
Multiple Environments, Multiple Systems
An additional problem is that many physicians practice in multiple environments. They spend the morning in clinic, the afternoon performing outpatient surgery, and the evening rounding on inpatients. Despite attempts at interoperability, most have their own electronic medical record (EMR) systems.
“One gets accustomed to certain systems and then gets better at using it,” said Hardeep Singh, MD, MPH, chief of the Health Policy, Quality, and Informatics Program at the Center for Innovation in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center in Houston. “But if every place you went had a different medical record system, your comfort level in looking for or entering patient information would almost certainly go down.”
There is little standardization across these systems, even on such fundamental issues as displaying patient data. While he realizes it is impossible to standardize everything, he also said there are certain high-risk processes that we have to get right with technology. One of these is patient identification. “Technology could be useful in this area but also must be used correctly,” said Dr. Singh, who was one of the authors of the ECRI report. “It has certainly made the system more transparent, and we can measure things more easily. It is easier to see when problems develop because it is documented in an EMR instead of a paper record that no one could ever find.”
The complexity of medicine makes WPEs possible. Multiple diagnostic tests, more patients, and more providers are involved in patient care, all of which increase the chance of error. Physicians are getting more information to diagnose patients than just a history and physical and basic blood work. Additionally, as the patient population ages, medical complexity and the opportunity for errors increase even more. “Between increasing time pressures, increasing patient volumes, and increasing complexity of the patients we are treating, there are certainly ample opportunities for error,” said Dr. Brenner. “This is not only in patient identification issues, but all other aspects of care.”
It appears that there is no one area of the process that can resolve all problems. Dr. Shah’s work found the domains with the most reported errors were technical (27.9%), administrative (12.2%,), diagnostic testing (10.8%), and surgical planning (9.9%). Technical and surgical planning had the highest levels of major morbidity at 71% and 45.5%, respectively.
All the experts agreed that there is no such thing as a small error. Left unaddressed, near misses may not miss the next time, and many little problems combine to become bigger ones. “There is a classic model that relates problems to Swiss cheese,” said Dr. Shah. “For an error to turn from a near miss to affecting a patient, it has to slip through various holes in the cheese. All these holes have to line up, but in healthcare there are, on average, eight slices of cheese.” This would mean that there are also eight chances to prevent an error. Otolaryngologists should know that there will be problems in their practice and, with this knowledge in mind, find ways to “block and tackle” at multiple points.
“Practices don’t realize that they can lean on the performance and quality improvement departments of the hospitals they have affiliations with. These departments can help with materials, literature searches, and plan-do-study-act cycles.” —Rahul K. Shah, MD, MBA
Prevention is largely about reporting: If you see something, say something. Leadership buy-in may be the single most important part of addressing WPEs.
“If you have leaders pushing away reports, being smug, and not creating the right culture, problems follow,” said Dr. Shah. “With any size of practice, you need to talk about safety and quality. It doesn’t have to be formal, and don’t overthink it. Something as easy as a safety huddle a couple of times a week goes a long way toward shaping the culture.”
Key components of a successful event reporting system include:
- A supportive environment that protects the privacy of the staff reporting occurrences;
- Reporting mechanisms that are easily accessed by the entire team, not just physicians and nurses;
- Summaries of reports and actions taken that are disseminated in a timely fashion so the staff knows their reports are important and are taken seriously; and
- Mechanisms in place to ensure that the responsibility for reviewing reports and developing action plans is clearly outlined.
“Medicine is very much a team sport, and there is a growing awareness that inter- and multidisciplinary teams are critical in achieving favorable outcomes for the patient,” said Dr. Brenner. “Start with the first person who touches the patient, either literally or virtually, including the front desk, nursing and medical assistants, and any other ancillary service. We are absolutely all in this together.”
Ask for Assistance
Physicians and their staffs shouldn’t be intimidated by an imposing and confusing set of concerns. “Practices don’t realize that they can lean on the performance and quality improvement departments of the hospitals they have affiliations with,” said Dr. Shah. “These departments can help with materials, literature searches, and plan-do-study-act cycles. They can leverage both these resources and those available from [their] malpractice insurance provider.”
Finding and addressing WPEs are part of the do-no-harm promise physicians make to their patients every day. “If you are not a constant student of safety and quality and you are not a student of your results as a physician, then you are not going to get better,” said Dr. Brenner. “If there was nothing to be done, we’d counsel patients that these things happen, but it wouldn’t change lives much. The fact that we know that by doing some simple things we prevent these ‘wrong’ things puts the onus squarely on us to find and act on them.”
Kurt Ullman is a freelance medical writer based in Indiana.