159 - What’s in a Name? A Multidisciplinary Journey to Safer Patient Identification

Description: The Joint Commission's National Patient Safety Goals (NPSG) emphasizes the importance of accurate patient identification, particularly in surgical settings.
At a large Level 1 Trauma center with 21 Operating Rooms, that serves a highly diverse patient population with 20+ different languages, an accurate patient identification was challenging. A common issue is the interchangeability of first and last names, and multiple first names which increase the risk of identification errors. This involves mismatched patient identifiers across the patient chart, ID band, and consent form. This resulted in significant case delay and patient and staff dissatisfaction. This prompted our frontline staff and leadership team to perform a comprehensive review of the patient verification process from the patient's initial contact.
A root cause analysis revealed inconsistent process in check in process across the clinical, admitting and pre-operative areas. This lack of a standardized procedures introduced vulnerabilities, particularly during transitions to the preoperative holding area. A multidisciplinary Performance Improvement (PI) initiative was launched involving staff from Patient Admitting, Patient Access, Quality and Safety Department, surgical and nursing teams using Plan-Do-Study-Act model. The goal were to strengthen patient verification practices and improve overall patient safety.

Key interventions included the standardization of the Patient Verification Policy, which mandated the use of government-issued identification as the primary method of verification. Comprehensive staff training across all departments, featuring targeted small-group sessions designed to emphasizing the critical importance of accurate patient identification. Additionally, existing policies and procedures were reviewed, reinforced, and re-integrated to promote compliance and foster a culture of safety.
The implementation of this performance improvement (PI) project resulted in measurable outcomes: discrepancies in patient records were eliminated, surgical delays were minimized, and overall operational efficiency improved. This initiative underscores the vital importance of interdepartmental collaboration and standardized protocols in achieving accurate and reliable patient identification. By addressing a specific safety incident through a structured improvement process, our facility not only resolved the immediate concern but also demonstrated a sustained commitment to patient safety. This project highlights the value of proactive problem-solving and continuous quality improvement in healthcare.