Clinical Incidents Discussion Paper

Clinical Incidents Discussion Paper

The purpose of this paper is to discuss patient identification as a clinical incident, using practice examples. Clinical incidents reports is a structured approach for addressing patient safety issues in the clinical environment. It is in line with nurses’ intentions to offer diligent, compassionate and benevolent care, an aspiration that is limited by patient misidentification incidences. The present case discusses a patient misidentification incidence that involved a patient whose medical records had been confused with those of a patient sharing a similar name. Applying the facility protocols and consulting with the patient helped in correcting the issue and ensuring that the patient received the appropriate care. Still, the facility protocols are based on human systems that are faulted for creating opportunities for human errors that could have a negative impact on care. Given this awareness, the recommendation is made that an automated patient identification system should be implemented and complemented with color coded wrist bands to address the shortcomings of the facility protocols. The paper makes it clear that technology should be integrated with human input to address patient misidentification as a clinical incident in nursing care.Clinical Incidents Discussion Paper

Clinical incidents paper


A clinical incident refers to any unplanned event that has the potential to cause or actually causes harm to a patient. Medical personnel are encouraged to acknowledge and report all clinical incidents (including actual occurrences, complaints and near misses) so risks to patient safety are identified and action is undertaken to mitigate the risk to acceptable levels and prevent future recurrences. It is important to note that although clinical incidences are mostly caused by human error, routine assignment of blame and quick judgments obscure the complex truth that identifying the source of the incident as departure from good practice is only one step in a series of steps to address the incident and prevent future occurrence. It is notable that although a particular omission or action by medical personnel may be the immediate cause of the clinical incidence, closer evaluation would typically reveal that departure from safe practice or a series of events influenced the wider organizational context and working environment. Still, it is important to note that formal protocols are often applied to address these incidents through ensuring efficient, comprehensive and systematic investigations. In fact, protocols reduce the possibility of routinely assigning blame and offering simplistic explanations, acting as opportunities for enhancing patient safety and risk management (Carlfjord, Ohrn & Gunnarsson, 2018; Gartmeier et al., 2017). The present paper applies a systematic approach to describe a practical encounter with a clinical incident from the perspective of a nurse, strategies that were implemented to address the incident, perceived outcomes, and lessons learned from the experience.


Medical personnel (including nurses) are part of a profession that views itself as diligent, compassionate and benevolent. It is not their intention to hurt patients or create situations in which they are hurt because of incidents concerning patient safety. However, harm to patients still occur. Misidentification of patients is one of the more common harms, and is an acknowledged problem within the clinical environment. In fact, it is not an uncommon problem when dealing with large volumes patients who undergo complex medical procedures. It is the outcome of a cascade of missteps that involve multiple persons and processes that ultimately end at the bedside. Despite the best intentions, medical personnel with from time to time misidentify patients because of the systems and processes being imprecise and fallible (Ferguson et al., 2019). Clinical Incidents Discussion Paper

The specific clinical areas that present room for patient misidentification include surgical interventions, blood transfusion, phlebotomy, and drug administration. The likelihood of this error occurring is increased by patient factors that include severe illness, language difficulty, dementia, confusion, advanced age, and multiple pathology. These factors make it difficult for nurses to communicate with patients in relation to medical history, drug lists, medical management, and identity. The most frequent patient misidentification incidences occur in emergency context, patient transfer and absence of identity control, and are caused by wrong labeling, administrative issues, wrong file notes and charts, and missing wristbands. Patient misidentifications typically result in infants being discharged to the wrong families, medical procedures being conducted on the wrong person, testing errors, transfusion errors, and medication errors (Bartlova et al., 2015). Because patient misidentifications is a root cause for many other clinical errors, it is not surprising that it received much attention in the clinical care environment, as is the present case.

Description of the incident

The patient misidentification incident involved an 82 year old women who have been receiving treatment at the facility for six months. Mrs. X (the patient) is a widow who lost her husband eight months ago. She was lonely staying alone in her home and decided to move across the country to stay with her daughter, her only surviving immediate family. She made the move to spend more time with her grandchildren and receive home-based care from her daughter since she had mobility problems owing to a back surgery that she had undergone after a car accident five years ago. She made the move with hard copies of her medical records. Unfortunately, Mrs. X suddenly fell ill two weeks into the move with her daughter. Since the illness was sudden, her daughter was concerned and brought her into the emergency room for a checkup. While sitting in the waiting room, the daughter took out her mother’s medical records and perused them. The records indicated that Mrs. X suffered from kidney cancer and should have started chemotherapy treatment three weeks ago but was yet to begin treatment. As a nurse who was part of the care team for Mrs. X, I made the recommendation that she should begin treatment for the kidney cancer immediately so as not to exacerbate her condition. The care team considered my recommendation and opted to consult Mrs. X over her treatment approached. She was shocked that she had been diagnosed with kidney and was supposed to have started treatment. She was adamant that she was not aware of this. As a result, the care team decided to consult the previous medical facility to collect more accurate information on her medical condition. The facility corroborated the records that her daughter had and insisted that Mrs. X was aware of her condition and was undergoing treatment as scheduled. Mrs. X and her daughter were shocked and insisted that she was undergoing kidney cancer treatment. To address the situation, it was resolved to subject the patient to a laboratory test to definitively determine whether or not she had kidney cancer. The test was conducted and it was determined that other than some back pain (from the previous back surgery) and acclimatization issues (following her move across the country), Mrs. X was in relatively good health and did not suffer from kidney cancer. This information was communicated back to her previous facility where it was determined that she had been misidentified since her medical records included information on another patient who had a similar name to Mrs. X. The issue was resolved, but I shudder when I consider what the result would have been should my initial recommendation been adopted and Mrs. X subjected to treatment for kidney cancer.

Strategies and solutions that were implemented

Although the misidentification incident concerning Mrs. X stood out for me owing to the potential serious negative implications for the patient, it was just one example in a long list of patient misidentification incidences during clinical encounters that the facility has experienced. The facility has detailed three approaches to address the issue. In fact, these three approaches were applied to the incident involving Mrs. X.

The first approach entailed implementing systems at the organization level to link the patients to the right medical records. It requires that the identity of patients be confirmed using a nine-step process. The first step was to emphasize the responsibility of medical personnel to check the patient’s identity and match it to the correct care before administering care. The second step was to encourage the use of multiple identifiers to verify the identity of the patient upon being admitted into the facility and prior to medical care being administered. The third step was to standardize patient identification approaches through the use of wrist bands containing a summary of the demographic information on the patient. The fourth step was to apply clear protocols to definitively identify the patients whose medical records did not provide a clear identity, and distinguish patients with the same name. The fifth step was to encourage the patient and family members to participate in the identification process, and confirm previous diagnoses and ongoing treatments. The sixth step was to discuss current diagnosis and treatment with the patient, as well as compiling the medical records in the presence of the patient. The seventh step was to apply clear protocols for handling and labelling laboratory specimen and results throughout the pre-analytical, analytical and post-analytical processes. The eighth step was to follow clear protocols that questioned medical history that did not match the laboratory test results. The final step was to repeatedly review and check medical records and not assuming that they were accurate as presented in order to prevent errors from being multiplied during the care process. Clinical Incidents Discussion Paper

The second approach involved orientation training for all medical personnel on the latest facility procedures for verifying and checking the identity of patients. The final approach was to educate patients and their family members on the need to correctly identify patients and match them to accurate medical records while addressing privacy concerns.

In addition to the three approaches, the facility has a patient identification protocol for handling all patients (whether new or return patients) upon coming into contact with the facility. The protocol’s policy is emphasis on the primary responsibility of medical personnel to verify and check the identity of patients, and actively involving them in the identification process. Upon admission and before care is administered, every patient is provided with a wrist band with basic demographic information on the patient, which acts as an identifier. An organizational protocol is used to identify patients with the same demographic information, such as those with the same name. Even if the patient is familiar to the medical personnel, there is a requirement that the identification details be checked at every encounter and before care is provided. Ensuring that patients and their family members are involved in the identification process.

Perceived outcomes

Applying the identified procedures and protocol ensured that Mrs. X was not misidentified, and she received the treatment that accurately matched her prevailing condition. To be more precise, it prevented the medical personnel at the facility from offering the wrong treatment that may have had a negative effect on the patient’s health and increased the cost of care, while presenting grounds for insurance claims to be denied (Tollefson et al., 2019). Overall, the patient identification system applied at the facility has eliminated opportunities for misidentification errors reaching the patients.

Lessons learned

The situation made it clear that the facility’s patient identification process significantly reduces opportunities for misidentification. In addition, it has leveraged patient involvement in verifying the identifying information and confirming that it is correct. Although the process was effective in addressing the misidentification case of Mrs. X, it is essentially a human controlled and managed process that presents opportunities for human errors. In essence, it significantly reduces the opportunities for misidentification errors, but does not eliminate the errors. Besides that, it presents other issues. Firstly, it is dependent on support from other medical facilities, and this could be an issue since it involves patient privacy and confidentiality. There were no guarantees that the other facility would have verified Mrs. X’s medical information since this information is protected by confidentiality laws. Secondly, the process can compromise the relationship between medical personnel and patients since the patient is repeatedly asked to verify his/her identity. Thirdly, it fails to consider the reality of clinical care setting, especially in emergencies when delayed treatments can have catastrophic effects. Fourthly, it increases the workload for the medical personnel, and time they spend away from patient care as they verify the patient’s identity. Fifthly, there is a possibility of the patient’s privacy and confidentiality being compromised as the medical information is checked and verified. Finally, there is a high potentially for cultural issues arising, such as clothing that conceals identity and stigma linked to the use of wrist bands (Tollefson et al., 2019). Clinical Incidents Discussion Paper

Looking forward, there is a need for the facility to implement an automated patient identity verification system that uses biometrics, radiofrequency tags, bar coding, and electronic order entry. An automated system that is adapted for the workflow processes would reduce human involvement in the identification system and address the presented shortcomings while reducing the potential for human errors occurring. In essence, implementing an automated system makes use of standardized patient identification systems that allow the medical personnel more time to assess medical processes, complements human checking processes, reduces opportunities for errors to be masked and replicated, and helps in protecting the patients’ privacy and confidentiality (Ferguson et al., 2019). Besides the use of automated systems, the wrist bands should be color coded to facilitate rapid visual identification of the patients for specific medical issues (Tollefson et al., 2019). The implication is that technology should be integrated with human input to address patient misidentification as a clinical incident in nursing care.


Bartlova, S., Hajduchova, H., Brabcova, I. & Tothova, V. (2015). Patient misidentification in nursing care. Neuro Endocrinology Letters, 36(Suppl 2), 17-22.

Carlfjord, S., Ohrn, A. & Gunnarsson, A. (2018). Experiences from ten years of incident reporting in health care: a qualitative study among department managers and coordinators. BMC Health Services Research, 18, 113. DOI: 10.1186/s12913-018-2876-5

Ferguson, C., Hickman, L., Macbean, C. & Jackson, D. (2019). The wicked problem of patient misidentification: how could the technology revolution help address patient safety? Journal of Clinical Nursing, 28(13-14), 2365-2368. DOI: 10.1111/jocn.14848

Gartmeier, M., Ottl, E., Bauer, J. & Berberat, P. (2017). Learning from errors: critical incident reporting in nursing. Journal of Workplace Learning, 29(5), 343-356. DOI: 10.1108/JWL-01-2017-0011

Tollefson, J., Tambree, K., Jelly, E. & Watson, G. (2019). Essential clinical skills: enrolled nurses (4th ed.). South Melbourne: Cengage Learning Australia.



Clinical Incidents Discussion Paper