Registration-associated patient misidentification in an academic medical center: causes and corrections

Jt Comm J Qual Patient Saf. 2007 Jan;33(1):25-33. doi: 10.1016/s1553-7250(07)33004-3.


Background: Proper patient identification is a major factor affecting patient safety in any health care organization.

Methods: An interdisciplinary team, using three Plan-Do-Study-Act (PDSA) cycles, reviewed the incidence of patient misidentifications resulting from registration process errors. Retrospective and prospective data were collected to determine the incidence among inpatients and outpatients.

Results: Registration-associated patient misidentification errors occurred 7 to 15 times per month. Information systems deficiencies, inadequate training, and the lack of a single master patient index were among the root causes identified. After three PDSA cycles, the incidence rate for registration-associated patient misidentification errors declined for inpatients (80.5%) but increased for outpatients (30.2%).

Discussion: Through an iterative process as implied in the PDSA cycle, registration-associated patient misidentification errors for established Johns Hopkins Hospital patients were dramatically reduced. A checklist is provided for other organizations to assess their vulnerability to registration-associated patient misidentification errors. The checklist suggests, for example, that organizations strive to develop a single master patient index and limit access to registration systems to staff with proper training and performance expectations.

MeSH terms

  • Academic Medical Centers
  • Humans
  • Interdisciplinary Communication
  • Medical Errors / prevention & control
  • Patient Identification Systems / organization & administration*
  • Process Assessment, Health Care / organization & administration*
  • Prospective Studies
  • Quality Assurance, Health Care / organization & administration*