Managing patients with identical names in the same ward

To review the experience of managing two patients with identical names in the same ward during a five-month period.

The records of the patients were reviewed to look for incorrect entries, errors in specimens sampling, administration of blood products and chemotherapy, and misplacement of clinical notes. Doctors and nurses involved were also invited to complete a questionnaire study to comment on the usefulness of the measures implemented for correct patient identification. A random sample of 60 patients was also selected to see if their full names were shared with other patients attending the same hospital.

Among the 1442 sheets of hospital records from the two patients, no errors pertaining to the clinical activities were found. However, 13 (0.9 per cent) sheets of the hospital records were misplaced. The 21 doctors and nurses participating in the questionnaire study gave positive support to all the additional measures implemented for safeguarding patient identification, of which the automated alerting feature in the electronic clinical management system received the highest scores. A total of 32 (53 per cent) of the 60 sampled patients shared a common full name with one to 101 other patients attending the same hospital.

Patients with identical names staying in the same ward present a unique challenge to acute health-care settings. The situation is especially relevant in communities where most people's names are not unique. Specific guidelines and measures are needed to prevent patient misidentification. Errors in filing of patient notes and laboratory reports to the hospital record deserve further attention.