Quality Improvement

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Reducing patient misidentification

Reducing patient misidentification

What is patient misidentification?

Patient safety incidents and near misses associated with incorrect patient identification are a recognised international problem.  The failure to correctly identify patients continues to result in medication errors, transfusion errors, wrong person and wrong site procedures, and diagnostic testing errors.

Common patient misidentification incidents occur when:

  • the wrong patient receives a diagnostic test / treatment / medication
  • a patient's clinical notes / medical chart / samples / results are mislabelled

What are we trying to achieve?

Value: Better, Best, BrilliantAccurate identification of patients and administering the intended clinical care is one of the most fundamental components of the provision of good health care.

Learning from patient misidentification incidents is essential if we are to continually improve the safety and quality of the care we provide.  We undertook a review of the reported patient misidentification incidents to find out if there was a problem and, if so, what improvements we needed to make to prevent these incidents from happening.

What did we find?

In order to understand how, where, and why we were misidentifying patients in our hospitals, we needed to look at all the information we had about these incidents.

1. How many patient misidentification incidents were reported from Jan 2012 - May 2013?

Overall 77 incidents were reported between January 2012 and May 2013

Chart of Patient Misidentification Incidents Jan 2012 - May 2013

2. Where were these incidents happening?

We found that over 80% were on two sites:

  • 58.4% at North Shore Hospital
  • 23.4% at Waitakere Hospital

Chart of Patient Misidenfication Incidents by Site

3. At each hospital where were the incidents occurring i.e. location?

We found that most incidents occurred in:

  • North Shore Hospital’s Emergency Department (ED NSH)
  • North Shore Hospital’s Assessment and Diagnostic Unit (ADU NSH)
  • Waitakere Hospital’s Emergency Department (ED WTH)
  • North Shore Hospital’s General Medicine Wards (Gen Med NSH)

Patient Misidentification Incidents at North Shore Hospital Chart
Patient misidentification incidents at North Shore Hospital (NSH)

Patient Misidentification Incidents at Waitakere Hospital Chart
Patient misidentification incidents at Waitakere Hospital (WTH)

4. What type of patient misidentification incidents were they?

We found that 81% of all reported incidents were categorised as "wrong patient / resident”

  • 68.9% of these incidents were related to medication / fluid errors

Patient Identification Incidents Chart

5. What type of incidents make up the category of "wrong patient/resident"?

We found that:

  • 48% were face-to-face incidents:
    • wrong medication given to patient
    • diagnosis / treatment errors
  • 52% were documentation incidents
    • wrong patient name documented
    • wrong label on patients notes / samples
    • wrong patient radiology referral
    • wrong patient label on diagnostic test

We also identified:

  • a lack of general knowledge of the standards for the correct identification of patients face-to-face 
  • that we do not have an organisation-wide policy or procedure guiding staff as to the correct identification process.
  • there was no pattern over time to when or where the incidents were happening

What can you do to help us?

Patients and families can help us by being involved in their care by:

  • making sure the hospital staff confirm your name and date of birth
  • asking the hospital staff questions when they are providing care / treatment such as:

Who are these medications for?

What is the name of the patient on that form?


What we did

Face-to-face identification

To improve face-to-face patient identification we selected a known tool called AI²DET .

What is AI²DET?

AI²DET is a standardised face-to-face process that staff can follow based on the acronym AI²DET (Acknowledge, Introduce, Identify patient, Duration, Explanation, Thank you).  It aims to improve face-to-face communication between healthcare workers, patients and whanau.



  • Knock before entering a room
  • Smile, makes eye contact
  • Greet the patient in pleasant manner



  • State your name 
  • Explain your role and why you are there



  • Ask the patient to provide their full name and date of birth
  • Visually check the patients wristband is correct



  • Tell the patient how long it will take, give time expectation



  • Help patients understand what we are doing and why
  • Keeps patient informed of any delays


Thank YouThank You

  • Thank the patient for their time
  • Express appreciation
  • Ask if there is anything else you can do for them

To test the feasibility of the AI²DET tool we undertook a pilot programme.

  • We trained 25 orderlies from our North Shore Hospital emergency and radiology departments.
  • The pilot ran for 3 months.
  • We audited the orderlies use of the AI²DET tool using observational audits.
  • We identified that while some orderlies were completing parts of the of the AI²DET tool consistently, some of the components were being missed.  So, additional coaching was provided.


Our audit of the use of the AI²DET tool showed us that it takes time for staff to adjust to a formalised patient interaction process.  However, over time there has been a significant increase in the use of all components of the AI²DET tool.


First Observation %

Last Observation %

% Difference






















Where to from here?

We want to test whether the AI²DET tool can make a difference to our patients’ experience and helps improve our patient identification process.

We are looking at ways we can collect data that will show whether we are making a difference and expanding our pilot programme.