Patient Photos Help Reduce Hospital's Medication Errors

When a new patient enters a hospital, staff members generally follow the same routine. The admitting nurse asks the patient's name, date of birth, symptoms, and any allergies to medications. From this information, a medical record is created and the patient may be admitted and is taken to a room.

However, at JPS Health Network in Fort Worth, TX, there is one extra step for admitting nurses in the Department of Psychiatry: photographing new patients.

This extra step was implemented in early 2006 when Allison Mason, RN, BS, MHA, program manager in the Department of Psychiatry at JPS, attended a monthly performance improvement review regarding medication errors.

After a medication error occurred on the adult inpatient unit resulting from the misidentification of a patient, Mason and the committee reviewed other patient identification practices on various units within the hospital's psychiatry department.

They found that the adolescent inpatient unit used patient photographs as a second identifier during medication administration and had only two recorded medication errors because of misidentification in the five years after implementing this process.

The committee rolled out this process on the adult inpatient units after hearing of its success on the adolescent unit. In the four years since photos have been used, there have been only a handful of medication errors in the JPS adult inpatient unit. When later addressed, these errors were found to have occurred because nurses had failed to use the patient photograph as a second identifier. These nurses were educated further about the process using a root-cause analysis and examining the occurrence step-by-step, says Mason.

Medication errors because of patient misidentification are especially challenging in psychiatry because patients are frequently noncompliant with wearing identification bands, are unable to answer identifying questions, or intentionally answer incorrectly, says Mason.

"In psychiatry, patients sometimes are not able to answer identification questions," says Mason. "The patient may be psychotic or unwilling to answer questions correctly, which presents the department with unique challenges."

Although patient photographs may raise a red flag for many working in healthcare and hospital settings as a possible violation of HIPAA laws, Mason says it is different for psychiatric units. HIPAA laws protect the privacy of patient health information.

"Our state laws and other regulatory standards we have to abide by are actually more strict," says Mason. "We explain to the patient what the picture is used for and how it improves their safety and quality of care."

When a patient is admitted, the admitting nurse takes a picture of the patient, which goes on his or her chart as well as a 3x5-inch index card.