1. Classen, Julie RN, BSN

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I applaud the article that appeared in the April edition of Nursing Management entitled "A Case of Mistaken Identity: Staff Input on Patient ID Errors." Because patient ID practices play such a critical role in patient safety, I found this article, highlighting the benefits of staff involvement, to be very appropriate. Certainly nurses take many steps to help patients safely navigate through their hospital stay, but no single step is as important as ensuring the correct identity of their patients. Accurate patient ID should be considered the building block or foundation of a safe hospital experience. Any crack in that foundation threatens the structure's stability, which may translate into potential patient harm.


For organizations accredited by The Joint Commission, complying with National Patient Safety Goal 01.01.01 to improve the accuracy of patient ID has driven policy and procedure redesign. Organizational leaders can write policies and implement electronic systems to help prevent wrong identity scenarios, but only nurses providing direct patient care can best identify potential weaknesses in such systems and policies during episodes of care. In the referenced study, participants suggested that ID errors didn't usually result from complex policies but rather from not following established policies due to rushing and time constraints. Although maintaining compliance with every regulatory and accrediting agency standard can be overwhelming, virtually all nurses would agree that ensuring correct patient ID is an absolute necessity. By engaging staff members in policy design and setting expectations that nurses hold their peers and support staff accountable when identifying their patients, organizations will help guarantee more successful processes.


I once overheard a nurse ask a patient to state his name, and then she proceeded to verify his medical record number. She quickly followed this with, "I'm sorry I have to ask you these questions, but 'they' make us ask." I remember thinking how that nurse lost a golden opportunity to educate her patient and validate the organization's commitment to patient safety.


While hospitals work to promote and maintain a culture of safety for their patients, staff, and physicians, implementing processes that incorporate repetition and standardization is imperative. As the authors suggest, asking open-ended questions to verify patient ID can prevent wrong assumptions when identifying patients. In addition, taking extra care when administering medications and blood products and when labeling specimens can prevent cases of mistaken identity and serious error. By designing practices based on staff nurses' input, as well as their commitment to safety, effective patient ID processes are sure to be successful.


Julie Classen RN, BSN


Florida Atlantic University