The Impact of Patient Misidentification

AHIMA and CHIME members have shared several real-life examples of issues that have resulted from patient misidentification. Their stories are collected here.

MisFiled mammography results

A woman received a routine mammogram. She returned to her provider office for her annual physical the following year and mentioned she never received her mammogram results from the prior year. She expressed relief that nothing was found. Unfortunately, her results were misfiled in the chart of a deceased patient of the same name. When the woman received her results, they showed cancer that had become terminal after the one-year delay.

claim denied for emergency appendectomy

A patient presents for an emergency appendectomy, but the insurance provider denies the claim, citing prior removal of appendix. After further evaluation, it was determined the patient’s brother had used his insurance card years prior when he needed the procedure.

happy family
mislabeled biopsy

A biopsy needed to be performed on a patient. When the provider entered the room, she brought a previous patient’s information with her. The medical assistant also joined so she could oversee and help collect the biopsy. The medical assistant put the label on the specimen from the previous patient because that was the only chart the provider had in the room. The specimen was therefore sent to the lab with the wrong name on it. The lab questioned the sample after they went through their process to identify the sample. They called the clinic and luckily the provider visited the lab to verify the sample was indeed from the other patient. It was then re-labeled with the correct name and the lab did the pathology on the biopsy.

overlaid patient records

Two patients have the same first and last name and the same dates of birth. Their records were combined (overlaid) several times over a few years. Patient safety was jeopardized as the two distinct patients could have been harmed due to the combining of their records.

multiple first and last names

At hospital registration training, the trainer explained the importance of correctly identifying patients. She explained that there are five other people in the metropolitan area with her own first and last name and one that shares her same:

      • Date of birth (DOB) (month/day the same; years are different)
      • Spouse’s name
      • Wedding date (exact same!)
      • Physical characteristics (height, weight, hair, eyes, etc)
Failure to properly identify patient

Two siblings had appointments but came back to the exam room separately. The medical assistant failed to check multiple patient identifiers and documented on the wrong chart. The provider then went in and entered her note in the wrong chart. 

improper registration procedures

Patient was scheduled with the wrong DOB and address. When the patient registered, the DOB was not verified.

Same Name, different dob and zip

Annie B. Smith and Ann B. Smith have same DOB and same zip code. Their records were overlaid. Annie B. Smith gave birth to a healthy baby boy on July 23, 2006—a time for celebration before child protective services removed the baby from the mother. The reason? The day before, on July 22, 2006, Ann B. Smith was seen in the ER for a cocaine overdose. The baby boy was not returned to Annie B. Smith for three weeks and the facility suffered a multi-million-dollar lawsuit.

mislabeled lab results

A lab test in which a patient with a male gender name had a pap smear led to a lab canceling the order because they thought it was a mis-labeling. The female patient who had a pap smear had a name typically given to men.

Pediatric cancer mix-up

A grandmother called a hospital chief information officer requesting calls cease to her daughter, who had lost her son, the caller’s grandson, to pediatric cancer. The caller’s grandson shared a name with a child currently undergoing treatment for pediatric cancer. The caller’s daughter was receiving appointment reminders and ongoing outreach for the patient currently undergoing cancer treatment. The persistent calls were causing emotional distress to the daughter of the caller as she was still grieving the tragic loss of her son.

false identity in er

Patient X was brought into the ER by law enforcement and provided a first name, last name, and SSN. Six weeks later, a bill was sent to the father of alleged Patient X. After further investigation, it was determined the person who presented at the ER was falsely using Patient X’s identity. More than 100 or more hours of manpower were spent by the records department, provider, and legal team to resolve the issue.

duplicate patient records created

A patient presented unresponsive from an outside hospital as a transfer. Demographic details were provided, but no identifying data could be located in the EHR, so a new medical record was created. Days later the patient was responsive and alerted staff that they had been treated at the facility previously while using their middle name as their first name. Older medical records were identified and combined with the newer record. This was a near miss, as the patient’s current treatment could have led to negative drug interactions.

multiple births

Parents with multiples (i.e., twins, triplets, etc.) named their children either the same name with a variation in spelling; similar names; a nickname of an actual name; or after a parent while using the incorrect suffix.

Same childrens’ names, differing ages

Parents with non-multiples used the same name for children of differing ages. This led to the children’s records being combined and overlaid, placing them at risk.

same name, different patients

A medical assistant announced a patient’s first name and a man stood up and went to the exam room with her. Once in the room, the assistant did the intake and poked the patient’s finger for an A1C. Meanwhile, a different medical assistant called the same name and a patient stood up and went to the exam room with her. She did vitals and the check in process, and at the end of her intake, she asked for two identifiers. She then realized she had the wrong patient. She had documented in the wrong chart and found her correct patient was the one who had his finger poked, which was not needed.

incorrect chart

A medical assistant received a call from a patient, and she asked the patient their name and pulled up her record. There was only one patient with the name. She then asked for the date of birth but only heard the month. She put a note in the computer for the physician but realized she had not been told the full birthday and called back the patient. She then realized she had the wrong patient’s chart.

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