Cancer Treatment to the Wrong Patient: Why Does This Still Happen?

In 2002, the Joint Commission created its National Patient Safety Goals program, which was effective by the start of the following year. The No. 1 priority: improving the accuracy of patient identification.

To meet this goal, healthcare providers use at least 2 patient identifiers—usually, name and date of birth. However, a medical record number or another identifier can be used, as long as it is not the patient’s room or chair number or location. In addition, some facilities check bar-coded identification information on a patient’s wristband against information on a medication label or the patient’s medical record. A few facilities use biometric patient identification, such as retinal scanning or fingerprint confirmation.

The Joint Commission isn’t alone in its efforts to ensure accurate patient identification. American Society of Clinical Oncology (ASCO) and the Oncology Nursing Society collaborated to create chemotherapy administration safety standards to reduce the risk of error when providing adult patients with chemotherapy and give a framework for best practices in cancer care.

Although rare, wrong-patient errors, also called patient identification errors, can cause harm when one patient receives another’s cancer treatment. The degree of harm is unknown but may be significant, and even lethal. Consequently, verifying a patient’s identity using 2 identifiers is essential to reduce the risk of error.

With these efforts in place, why are wrong-patient errors still happening in cancer treatment facilities?

Consider this real-life example, which led to legal action: In a busy outpatient registration area, a recently hired clerk followed the facility’s procedure and entered the name printed on the patient’s driver’s license. She clicked the first name in the list that appeared on her computer screen and created a wristband, unaware that other patients with the same name existed in the system.

The clerk asked the patient if the information on the band was correct, and he said yes. In court testimony later, he stated that he was not wearing his glasses at the time and was relying on the hospital staff to apply the correct wristband.

The patient was sent to the busy infusion area at noon for his second chemotherapy treatment. A registered nurse asked him if his name was John Jones (name changed here for privacy) and if his birthday was the date that she read from his wristband. He nodded yes.

But an error was made. The patient received the chemotherapy intended for another patient who had the same name but a different birthdate.

In court, the patient said that although the nurse said the correct name but wrong birthdate, he didn’t notice, because the nurse had a “heavy accent” and “rattled off numbers.” He also stated that the infusion room was loud and busy and that he “didn’t hear well.” In the nurse’s testimony, she said the orders were “unclear” because they were written as “day 1, day 8,” and she presumed the patient came in for treatment on the correct day.

Despite receiving the wrong treatment, the patient experienced minimal adverse effects. However, he alleged harm, and a jury agreed.

This case illustrates how a patient identification error can occur and go undetected. With increasingly larger patient databases, it is essential that registration staff select the correct patient from electronic lists. Patients with common names and those who have been registered under multiple names (eg, maiden name and married name) are at a higher risk of identification errors. For instance, “Smith” is the most common surname in the United States—more than 2 million people have it—followed by “Johnson,” according to the US Census Bureau. Also, it is not uncommon for patients with the same or similar names also to have the same or similar birthdates. These patients need to be informed that another patient with the same primary identifiers exists in the system. That way, patients can help ensure that their identity is correctly confirmed.

Had the nurse asked for the patient’s name and had him state his birthdate, the error might have been avoided. Active confirmation of identity, instead of passive confirmation of identity, is best. The case also illustrates how patients tend to rely on healthcare providers instead of being active participants in the identification process. Patient education and engagement in the identity verification process is crucial.

Identification challenges exist in cases where a patient may be unable to participate in the process for reasons such as cognitive impairment or language barriers. These situations need to be addressed on a case-by-case basis using available resources.

Although a patient’s photo should never be used as an identifier, it can be used as an additional verification method. Bar codes, too, should not be relied on but can be an additional identifier.

Electronic systems should allow just 1 patient record to be open at a time; with some older systems, multiple records can be open simultaneously, increasing the risk of errors. Labels containing patient information should be printed and used one patient at a time; batch labeling could result in the wrong label being applied to a blood vial or, worse, a chemotherapy infusion bag. The test result review should include verification of patient identity information. It is not uncommon to find reports, particularly those of tests performed at another facility, scanned or entered into the incorrect electronic medical record. Perhaps most important, patient identification should be verified upon every encounter that requires confirmation, not just at the onset of care delivery that day. For example, patient identity needs to be confirmed before each infusion bag of chemotherapy is administered, even in facilities where nurses feel they “know” their patients. When safety processes, such as verification of patient identity, are performed consistently and attentively, errors can be prevented.