AHRQ Innovations Exchange | Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification

Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification

Snapshot
Summary
To prevent errors resulting from patient misidentification, caregivers in adult and adolescent psychiatry units use photographs as a second means of identifying patients (in addition to the traditional approach of verbally verifying the patient's name and matching it to the name on his or her wristband) before dispensing medications, drawing blood, running laboratory tests, or providing other forms of care. The program has virtually eliminated medication errors due to misidentification, with the incidence of such errors declining dramatically on the adult unit, to a level comparable to that achieved on the adolescent unit (where the approach has always been used).

Evidence Rating
Moderate: The evidence consists of before-and-after implementation comparisons of medication errors due to misidentification.

Developing Organizations
JPS Health Network
Fort Worth,

Date First Implemented
2000
The program has been used on the adolescent unit since it opened in October 2000; the adult unit adopted the use of photo identifiers in February 2006.

Patient Population
Age > Adolescent (13-18 years); Adult (19-44 years); Middle-aged adult (45-64 years); Senior adult (65-79 years); Vulnerable Populations > Mentally ill

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AHRQ Innovations Exchange | Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification