Risk Profile: Care – Wrong patient/site/procedure

Risk Profile: Care – Wrong patient/site/procedure (PDF version)

This Risk Profile provides information on risk mitigation strategies to verify that the person receiving the service or treatment is the correct patient. The risk mitigation strategies are intended to keep patients safe and reduce risk of potential errors. This document contains information entered by your peers in the Risk Register application to help you manage this risk.

Ranking/ratings[1]

  • Likelihood – average score 2.58
  • Impact – average score 3.25

The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key controls/mitigation strategies

  • Patient identifiers
    • Clearly defined policies and standard procedures for at least two patient identifiers before any treatment, or service provision
    • Use of patient identifiers specific to the individual (e.g. date of birth, first and last name, address verification)
    • Inclusion of the patient as an active participant in the process of two patient identifiers. If the patient is confused or non-verbal, standard procedures developed
    • Barcode technology as an adjunct to patient identification
    • Staff education including patient identifiers practice alerts and refresher training
    • Visual cues utilized as a reminder for two patient identifiers prior to any treatment or service provision
    • Team huddle for regular communication and promotion of improvement opportunities
    • Annual review of accreditation standards related to two patient identifiers with action plan to address gaps
  • Information
    • Forcing functions as available when entering information into electronic systems
    • Automation – Lab Information Systems
      • Unique record number system within the lab to cross-check and assist to find if wrong record number has been put in to reduce test results going to wrong chart
      • If there is a discrepancy, test results are not transmitted until reviewed and manually released
    • Health Cards scanned at registration
  • Blood administration
    • Defined policy and processes of all issued blood products requiring blood sample(s) from the patient for cross-matching prior to issuing the blood product
    • Comparison of physician order against requisition received at time of blood administration
    • Process for labeling of blood specimen at the bedside and double check
    • Delivery of blood product process includes double-checks
  • Surgical
    • Surgical time out and surgical safety checklist implemented for communication and teamwork
    • Surgical site identification with engagement of patient prior to the patient being brought into operating room
    • Enhancing safety culture in surgical program to better identify patient risk
    • Feedback on positive patient identification, inter-professional team huddles
    • Simulation programs to support development

Monitoring/indicators

  • Compliance and monitoring of adherence to established standard practices through audits  
  • Competency testing for users and entering unique patient numbers
  • Incident reports, reviews, and analysis for trending
  • Staff engagement on surgical checklist completion and improvement opportunities

[1] As of January 1, 2018

Note: information presented in this document has been taken from the shared repository of risks captured by HIROC subscribers participating in the Integrated Risk Management program.

© 2018 HIROC. For quality assurance purposes.