Help Prevent Wrong-Patient Errors

You’re on the front lines to prevent wrong-patient errors.

These dangerous mix-ups can affect both the patient who WASN’T supposed to get a med and the one who WAS supposed to.

When confirming patient identifiers, ask open-ended questions rather than “yes” or “no” avoid misunderstandings.

For example, say “Tell me your name”...not “Are you Hugh Morris?”

When accessing patient profiles, follow policies for checking TWO identifiers...usually full name PLUS medical record number (MRN).

Using just one identifier is risky...due to the potential for same or similar names, typing mistakes, etc.

If your EHR includes a patient photo, glance at it before taking med another double check.

Ensure that the names match when meds have a patient label on the med package PLUS a patient label on an outer covering.

For instance, if you’re prepping insulin syringes for multiple patients, check the name on the syringe label before bagging it.

Placing one patient’s syringe in a baggie labeled with another patient’s name could lead to administration of the wrong insulin dose...and dangerously high or low blood sugar.

Take care to deliver meds to the right patient bin on patient care units. Consider looking at the patient labels on all the meds in a make sure they’re for the right patient.

Don’t check just a room number for a’s subject to change. And avoid using just last name and room number...a patient transferred in could have the same last name as one transferred out.

When returning home meds at discharge, verify the patient’s current room number. A room number on paperwork from when meds were checked in could be wrong, since the patient may have been transferred.

Keep in mind, wrong-patient errors are most likely in patients with the same last name...especially multiple births (twins, etc).

This is partly because newborns may not yet have first names...such as “Garcia, Baby Girl A” and “Garcia, Baby Girl B.”

Alert your colleagues to same or similar patient names. Highlight these on patient labels, note them on dry-erase boards in dispensing areas, and share info at shift changes.

If a nurse has trouble when scanning a med’s barcode, check whether they’re trying to administer the med to the wrong patient.

Key References

  • J Clin Nurs. 2018 Feb;27(3-4):715-724
  • (4-28-23)
  • ISMP Med Safety Alert! Acute Care 2019;24(8):1-6
Hospital Pharmacy Technician's Letter. May 2023, No. 390522


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