After heart disease and cancer, medical errors are the third leading cause of death in the United States and include misdiagnoses, incorrect anesthesia, delayed treatment, and patient misidentification.
Patient identification has been on the minds of healthcare leaders and policy makers for more than two decades. When the Health Insurance Portability and Accountability Act (HIPAA) was signed into law in 1996, it called for developing a national patient identifier that would solve patient misidentification by assigning a unique, permanent number to every individual in the United States. The idea was to implement a uniform approach for accessing a patient’s medical history across the healthcare system. After HIPAA became law, Congress blocked this effort over privacy concerns, and the issue gradually faded from public attention.
The near-universal adoption of electronic medical records and the push for interoperability has taken priority over other patient record efforts during the last decade until recently, when the U.S. House of Representatives voted to end the ban on establishing a patient identifier. Illinois Congressman Bill Foster said creating one would help reduce medical errors and deter "doctor shopping," a serious issue inflaming the opioid crisis.
ECRI Institute has long supported federal efforts to establish a patient identifier, joining with Rep. Foster, other congressional supporters, and key industry stakeholders. In a letter to Congress this summer, proponents cited our research in their call for support:
This problem is so dire that one of the nation's leading patient safety organizations, the ECRI Institute, named patient identification among the top ten threats to patient safety.
This has been a priority issue for ECRI for more than 15 years, and we’ve developed many resources to support establishing a patient identifier and end misidentification errors. The Government Accountability Office, in a report to Congress, referenced recent ECRI research developed through analysis of its Patient Safety Organization (PSO) adverse event data. This research examined nearly 8,000 adverse misidentification events from 181 healthcare organizations. Among the top findings:
- Nine percent of wrong-patient errors led to temporary or permanent harm, and two deaths.
- Seventy-two percent occurred during patient encounters and another 12 percent occurred during intake.
- Thirty-six percent involved diagnostic procedures like x-rays or labs and 22 percent involved treatment like procedures and medication.
Our research found that incorrect patient identification occurs during multiple procedures and processes. It occurs in every healthcare setting, from hospitals and nursing homes to physician offices and pharmacies, and is not unique to any one role.
As the patient identifier issue reemerges in Congress, ECRI Institute is pleased to support this important effort by lending our data-driven insights through discussions with members of the House and Senate.
Learn more about our work to prevent harmful medical errors as the largest federally designated Patient Safety Organization with nearly 3 million adverse event reports.