Single-Event Analysis: The Wrong Patient
One of the least defensible medical errors is performing a procedure on the wrong patient. These events are the result of human error, as previously discussed, but consideration of environmental factors is also warranted. Gray et al. (2006) concluded in an NICU more than 50% of patients were at risk of misidentification due to shared surnames, similar surnames, or similar medical record numbers. Chassin and Becher (2002) provide an insightful review of a situation in which one hour into an invasive electrophysiology study the medical team discovered that the adult patient undergoing the procedure did not need it and was not scheduled for it. Their account is discussed in three parts: data collection, data analysis, and corrective or preventive actions.
Data Collection
The event began with the admission of two patients with similar names; the pseudonyms Joan Morris and Jane Morrison were used. Morris was a direct admission to the telemetry unit and Morrison was a transfer. Morris was subsequently transferred from telemetry to oncology.
On the day of the procedure, electrophysiology telephones telemetry seeking Morrison, but an unidentified telemetry staff member incorrectly reports that she has been transferred to oncology, mistaking Morris for Morrison. Electrophysiology telephones oncology seeking Morris, and Ms. Morris’s nurse agrees to transport her to electrophysiology for the procedure despite the lack of a written order. Ms. Morris states that she does not want to undergo the procedure.
Ms. Morris and her chart are delivered to electrophysiology. Given the patient’s reluctance to undergo the procedure, the attending is called and despite having met Jane Morrison, the scheduled patient, the prior evening, the attending does not recognize that Morris is not Morrison. The attending instructs the nurse to prepare Morris for surgery and states that she has agreed to surgery.
An electrophysiology nurse notices the consent form is missing although the daily schedule reports that it has been obtained and notifies the fellow scheduled to do the procedure. The fellow notes a lack of pertinent information in the patient chart but proceeds to discuss the procedure with Morris and obtains her consent.
Approximately 45 minutes after Morris was transported to electrophysiology, an oncology resident discovers she is not in her bed and has been transported for a procedure. The resident goes to electrophysiology to determine why she has been transported there. Informed that she had been previously scheduled for the procedure, the resident assumes the attending has simply failed to inform him and he leaves the unit satisfied.
Approximately one hour and 15 minutes after transport, the procedure begins on Morris. Forty minutes later, a second nurse calls from telemetry to inquire why Morrison, the scheduled patient, has not been called to electrophysiology. At approximately the same time, the charge nurse in electrophysiology notices that Morris’s name does not match any name on the daily schedule. Neither discovery results in recognition of the misidentification. The telemetry nurse is told to send Morrison to the unit, and the charge nurse’s discovery is relayed to and dismissed by the fellow, who was at a demanding part of the procedure.
Approximately one hour after beginning the procedure, an interventional radiology attending goes to check Morris and is told she has been transported to electrophysiology. He follows up with electrophysiology, where the attending maintains that Morris is in fact Morrison. At this point, the charge nurse informs him that Morris is on the table and a review of patient chart bears this out. The procedure is stopped and the patient returned to oncology. The attending subsequently explains the error to the patient and her family.