This year, Rhode Island Hospital made headlines when they were reported for four cases of patient misidentification, all of which resulted in unnecessary and incorrect medical care[1]. In three cases, patients received imaging and/or diagnostic tests that were intended for another patient — actions which carry moderate risk but could be determined to be relatively neutral. However, in the fourth and most impactful case, a patient underwent an incorrect operation on the non-designated part of the spine, a shocking medical error which will have ramifications throughout the patient’s life. Rhode Island Hospital has made investments, financial and operative, to ensure that such errors will not occur again. However, such a case demonstrates that the issue of patient misidentification is still frequent in the United States healthcare sector, even in largely industrialized and sophisticated hospital systems. Particularly in the anesthesiology and surgical fields, addressing patient misidentification is crucial for effective,appropriate, and ethical patient care.
Patient identification refers to the confirmation that an individual is both (a) the person whom they claim to be and (b) receiving the services that are intended for the person whom they claim to be. If both conditions are not met in the healthcare setting, then this is considered a breach of patient identification and could imply both legal and medical ramifications for the health system. According to the World Health Organization, the major healthcare fields in which patient misidentification is most likely to occur are drug administration, phlebotomy, blood transfusions, and surgical interventions[2]. Inherent to anesthesiology is, of course, drug administration and surgical interventions, rendering patient misidentification as a core issue to the field.
Therefore, what specific interventions can anesthesiology and surgical practices make to avoid patient misidentification? In the age of an increasing emphasis on patient safety, there are many options at both the provider and practice level. At the practice management level, standards of practice should be related to all providers, from anesthesiologists to Certified Registered Nurse Anesthetists (CRNAs) to operating room nurses. Policies could include two corroborating patient identifiers as proof of identity, physical markers with the identity of the patient place on the patient at all time during stay, multiple verbal verifications, or dedicated time during the procedure to verify patient identity and site of surgery, for example[3]. In addition, policies must be enforced at the practice management level. Although anesthesia professionals are often highly booked, it must be a strategic priority of the operating room manager or chief of department to enforce standards of practice as related to patient identification, whether that means providing a team member or volunteer that is responsible for the task of patient identification or providing in-service ongoing training to practitioners to ensure education is up to the current standard.
In light of technological advancements, more sophisticated options for patient identification are entering the sphere of conversation. Several companies have come forth with advanced biometric identification solutions, such as matching the individual to the identity by utilizing palm-vein technology, thumb scans, two-step secure verification, or facial analysis techniques[1]. While such technologies may be expensive at first to integrate into each hospital system’s electronic medical records (EMR) system, they will likely prove to be the next generation method of securely verifying a patient’s identification.
In and out of the operating room, patient identification is critical for delivery of patient care, particularly in the anesthesia. By strengthening pillars of standards of practice and integrating novel biometric technologies, anesthesia providers as well as anesthesia management organizations, can ensure that hospital and health systems move forward in delivering enhanced care for patients.
[1] Miller, G. Wayne. “R.I. Hospital Enters Consent Agreement after 4 Patient Errors in 4 Weeks.” Providence Journal, Providencejournal.com, 9 June 2018, www.providencejournal.com/news/20180608/ri-hospital-enters-consent-agreement-after-4-patient-errors-in-4-weeks.
[2] World Health Organization, et al. “Patient Safety Solutions.” World Health Organization, 2007, www.who.int/patientsafety/solutions/patientsafety/PS-Solution2.pdf.
[3] AST Education and Professional Standards Committee. “Standards of Practice for Patient Identification, Correct Surgery Site and Correct Surgical Procedure.” Association of Surgical Technologists, Oct. 2006, www.ast.org.
[4] Wood, Megan. “How Biometric Identification Enhances Patient Safety and the Hospital’s Bottom Line.” Becker’s Hospital Review, Dec. 2017, www.beckershospitalreview.com/cybersecurity/how-biometric-identification-enhances-patient-safety-and-the-hospital-s-bottom-line.html.
Supplements known to increase the risk of bleeding include garlic (inhibits platelet aggregation), ginkgo (inhibits platelet activating factor), ginseng (inhibits platelet aggregation; also decreases blood glucose), saw palmetto (unknown mechanism), black cohosh (NSAID-like properties), chamomile (contains phytocoumarins which have an additive effect with warfarin), feverfew (inhibits platelet aggregation and has additive effects with antiplatelet drugs and warfarin), fish oil (dose-dependent), and vitamin E (can also affect blood pressure).
Alongside the security features, EMRs are more conducive to secure sharing amongst institutions. For example, if a patient decides to move healthcare providers or to seek a second opinion at a different institution, historically such a process would be laborious and require either direct mailing or faxing of health information — each of which are non-secure methods. However, with EMR, hospitals and healthcare providers can subscribe to Electronic Health Records, which are comprehensive software systems that allow for sharing amongst the licensed healthcare providers and institution that align. The inclusion of EHRs increases patient engagement in their own clinical journey, as well as the patient’s autonomy to move to the provider that they prefer for treatment.
Despite significant differences between patient groups in the Patzelt study (general anesthesia patients were younger but tended to have more severe disease and comorbidities, though pulmonary hypertension was more prevalent in the deep sedation group), both studies nevertheless found similar outcomes. There was no difference found between the two groups in terms of procedure success, surgical complications, major cardiac and cerebrovascular events, or postoperative pneumonia. Both studies found advantages to deep sedation, including shorter preparation time in the cath lab and ICU stay duration. The Horn study found longer procedure time and fluoroscopy time for the general anesthesia group, however this may be confounded by baseline patient characteristic differences between the two groups.