Patient identification is a patient safety issue according to the World Health Organization (WHO) and the Joint Commission. Misidentification of a patient can have serious adverse medical consequences—such as the dispensation of the wrong medication or even implementing the wrong medical treatment or procedure. Though the literature review of the Joint Commission and the WHO's safety protocols cite patient misidentification as a worldwide patient safety issue, none of them go into detail about the importance of correcting pronouncing and spelling names that are relatively uncommon in the United States. Incorporating the principles of the National Standards of CLAS and the patient identification safety issues identified by the Joint Commission and the World Health Organization, a set of Safety protocols when working with patients whose names are uncommon in the United States was developed using multiple academic studies and this case study.
As an inpatient in the psychiatric ward of the New York-Presbyterian Hospital (NYPH) in June of 2016, Seo-Young Chu, who is severely nearsighted, repeatedly asked the hospital staff for the pair of glasses she came into the hospital with. The staff told her she had not come into the hospital with glasses. In a tweet that sparked an investigation with the New York State Office of Mental Health (NYSOMH), Chu said the hospital staff essentially gaslit her by telling her that she did not have glasses with her when she was admitted into the hospital. Seo-Young also posted to the Facebook page of the NYPH that staff repeatedly mispronounced her Korean name. She could not see beyond a several feet in front of her and had difficulties navigating her environment in the hospital. After days of fighting for her personal belongings, she who was already suffering from PTSD, the symptoms for which include anxiety and self-doubt, was beginning to doubt whether she ever wore glasses. On the last day of her stay, a member of the hospital staff found her bag of personal affects, mislabeled "Young-Choo" (Please see above photo).
The investigation by NYSOMH prompted an internal review of the allegations at New York Presbyterian Hospital. The patient services administrator of the hospital responded to Seo-Young's allegations that the staff mispronounced her name and wrote the wrong name on the bag of her personal effects.
"The review found that one possible contributing factor to the issue of the mispronunciation of your name may have been that our staff are ethnically diverse with a range of accents which may have been construed as mispronunciation... Your statements were shared with the unit staff and they are sorry if in any way they you felt they were not sensitive. It was not their intention.
Regarding the incorrect spelling of your name on the bag containing your belongings. The review found that staff were verbally told your name when your bag was labeled staff in the Evaluation Center. We were made aware of this error and we apologize. No disrespect was made meant to you or your property. This was a deviation from our standards and we will verify the spelling of patient names for labeling any item in the future."
In a message April 10, 2023, Seo-Young disputes the accuracy of certain points in the letter and states that she would never have mispronounced her own name as the letter states. When asked how she felt about the outcome, she said "I was angry that I had to go through that experience in the first place. I was also terrified of being hospitalized again. I came out far worse than when I went in."
Safety protocols when working with patients whose names are uncommon in the United States
1) Ask the patient how to pronounce his or her name. Express your intention explicitly, "I don't want to mispronounce your name. Could you help me to pronounce your name correctly? Could you say your name slowly while I write down the phonetic pronunciation of your name in English?"
Demonstrating an effort to correctly pronounce and spell your patient's name will foster trust and respect and likely elicit a more responsive attitude.
2) Often times, the spelling of a name in English differs from the pronunciation of the name in its original language.
Be aware that the transliteration tables that Romanize words from its original writing system to English do not render a spelling that is phonetically equivalent to its pronunciation in its original tongue. Certainly, this is the case with Seo-Young's name, which is Korean in origin.
The first name Seo-Young is pronounced "SUH-young" and the last name Chu is pronounced "Choo." Spelling out the pronunciation of the name phonetically, specifying which syllables are the first and last names, on their medical chart would be help the next staff member who picks up the patient's chart.
Though this was not the case here, in many Asian and some African countries, surnames come before first names. It is very common for say their name leading with their surname. Therefore, it would be good to verify that the sequence that they're saying their name is first name, last name.
3) Asian American names are American if the person is an American citizen. While names of Asian origin are not Euro-American, saying that they are not "American" could be perceived a racial micro-aggression. Consider that some Asian groups such as the Chinese Americans and Filipino Americans have been in the United States for more than 300 years. Furthermore, while 70% of Asian Americans are foreign-born, many are either citizens by birth or naturalization. Inherently, staff should understand that you cannot tell by a person's appearance, language, or culture what their national origin or nationality is.
People with limited English proficiency can be American citizens because they could have taken the United States citizenship test in the language of their choice. The U.S. Citizenship test allows exemptions from its English proficiency exam based on certain set of rules.
4) An additional takeaway from this case study is that having an ethnically diverse staff is an asset to any hospital and this diversity is reason to insist that every effort should be made to pronounce patient names correctly.
References
Dali S, Atasuntseva A, Shankar M, Ayeroff E, Holmes M, Johnson C, Terkawi AS, Beadle B, Chang J, Boyd K, & Dunn T. (2022) Say My Name: Understanding the Power of Names, Correct Pronunciation, and Personal Narratives. MedEdPORTAL. 18:11284. https://doi.org/10.15766/mep_2374-8265.11284
Joint Commission. (2023). 2023 Hospital National Patient Safety Goals. Retrieved April 23, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/hap-npsg-simplified-2023-july.pdf
Just, B. H., Marc, D., Munns, M., & Sandefer, R. (2016). Why Patient Matching Is a Challenge: Research on Master Patient Index (MPI) Data Discrepancies in Key Identifying Fields. Perspectives in health information management, 13(Spring), 1e.
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