{
  "abstract": "Background Timely access to critical clinical and patient information is important, particularly in life-threatening events where rapid retrieval is crucial for appropriate care. The complexity of patient pathways, inconsistent identifiers and communication gaps increase the risk of misidentification during registration, transfers and handovers. While many errors can be prevented under normal circumstances, acute in-hospital emergencies present exceptional challenges. This review systematically describes the nature of patient misidentification during inpatient emergencies and identifies facilitators and barriers to accurate critical information at the point of care.Methods A multidisciplinary team conducted this review following a pre-registered protocol (CRD42024597656). Comprehensive searches in MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science, from January 2015 to September 2024 were accompanied by supplementary searches. Studies were included if they reported patient identification methods, misidentification risks, or access to critical information during emergencies. Quantitative and qualitative synthesis were integrated to create a comprehensive evidence base.Results Sixteen studies were included in the review. Numerous studies lacked adequate evidence on patient identification and critical information outcomes during emergencies. The review found that patient misidentification errors include medication errors, transfusion errors and wrong-patient orders. Strategies that reduced misidentification included combining re-entry of identifiers with distinct naming conventions in newborns (61.1% reduction from baseline); and displaying patient photographs in electronic health records (Odds ratio 0.57; 95% CI, 0.52–0.6).The use of ‘aliases’ for unidentified critically ill patients caused confusion, whilst intradepartmental communication issues led to clinical information discrepancies. Poorly designed charts in a maternity unit potentially limited accurate interpretation of early warning scores.Facilitators for accurate critical clinical and patient information include involving patients and families, standardising procedures, and staff training. Barriers include inadequate staff knowledge, poor communication, lack of clear policies, and chaotic work environments.Conclusion Patient misidentification is a systemic issue, compounded by high-pressure environments. This problem requires a multifaceted approach that involves collaboration of various stakeholders. Future research should prioritise evaluating (1) effective display formats, (2) interventions for timely retrieval and (3) person-related factors in using technology for accurate critical information.",
  "authors": [
    {
      "affiliations": [
        "Department of Medicine and Population Health, University of Sheffield, Sheffield, UK"
      ],
      "name": "Edith Poku"
    },
    {
      "affiliations": [
        "Department of Medicine and Population Health, University of Sheffield, Sheffield, UK"
      ],
      "name": "Katherine Jones"
    },
    {
      "affiliations": [
        "Department of Medicine and Population Health, University of Sheffield, Sheffield, UK"
      ],
      "name": "Lukasz Lagojda"
    },
    {
      "affiliations": [
        "Department of Medicine and Population Health, University of Sheffield, Sheffield, UK"
      ],
      "name": "Amber Muhinyi"
    },
    {
      "affiliations": [
        "Department of Medicine and Population Health, University of Sheffield, Sheffield, UK"
      ],
      "name": "Anna Cantrell"
    },
    {
      "affiliations": [
        "Department of Medicine and Population Health, University of Sheffield, Sheffield, UK"
      ],
      "name": "Andrew Booth"
    }
  ],
  "title": "P19 Positive patient identification and critical clinical information: a systematic review of misidentification errors, facilitators and barriers",
  "uid": "bac46948-9d2d-548a-b605-cde2f10bd27c"
}