I focused my Gemba Walk on our Registration Department and Emergency Department, focusing on John Doe patients’ medical records merging together. We had a patient that came in unresponsive, no identification, no family members found on the street that had to be transferred by life flight. Luckily this does not happen often at our facility that we are unable to identify a patient before we discharge or transfer them out. We needed to find a way to keep unidentified patient record separated from each other. This also brought up question if more than one John Doe patient came in on one specific day, we couldn’t just use the date as an identifier, which is what we have done in the past. Once these problems were identified and discussed the meeting was called for all the departments involved in admission and care dealing with the identified patient and coming up with a new system.
The collaboration of the team of the emergency room, medical records, and patient access came up with a new system consisted of coming up with alias name and using the date of service as the birth date. We decided that keeping Doe as the last name and adding alphabet letter to the first name Jane or John. example: Doe, AJohn/Doe, AJane – date of birth 02/01/2019, and once the alphabet has been completed adding a second letter. Example: Doe, AAJohn/Doe, AAJane and so forth. This will allow the names to stay together in our system and allow the registrars to see the last one used, eliminating a paper trail to refer to. We thought about using numbers with the name but with our system it does not allow us to add numbers within the name. When the patient is transferred a patient face sheet with demographics will go with the patient and the receiving hospital has our information to call/fax us any updated information on the patient the find and allow us to then go back in to that patient’s chart and update to the correct name and date of birth.
We are now in the process of writing up the new policy for not only our hospital but also our sister hospitals. The transition to the new process should have little resistance and will be simple to use resulting in less confusion for all involved, patient, admission, medical records and Emergency Staff. This is a simple but effective method for a rapid assignment of a unique alias for unknown patients.