Hygiene issues, adverse consequences of medication, poor judgement – all of these are recognized causes of serious medical errors that can harm patients. However simpler mistakes can often cause damage and go unrecognized as a threat to patient safety.
Patient misidentification was the cause of a serious medical error at Saint Vincent hospital this July when the wrong patient’s kidney was removed based on a scan that belonged to another patient. This case spurred the Boston Globe to request state records on wrong-patient procedure errors. The procedures included the insertion of intravenous catheters, endoscopies, and biopsies. Since 2011, there have been at least 14 wrong-patient procedures in Massachusetts, state records show. The Globe also found that in 10 out of 14 of wrong-patient procedure cases, the cause of errors was the failure to follow simple rules for identifying patients such as obtaining full name and birth date. Many of the patients didn’t speak English.
State investigations were conducted following the incident at Saint Vincent and another serious CT scan error at UMass Memorial. Despite health care safety experts’ reassurance that wrong-patient procedures are rare, these investigations showed that the patient identification errors that can lead to them are not. The investigations at both hospitals turned up underlying patient identification errors. At UMass Memorial a patient was diagnosed with cancer based on patient misidentification. Inspectors investigating the incident at the hospital found that even after the mistake was identified, test-results for the two patients were still mixed up. The investigation also found other errors.
That these errors are often discovered before a mistake happens is no excuse for not following procedure, according to Dr. Eric Dickson, president of UMass Memorial Health Centre, who cautions “If you fail to follow the procedures it’s only a matter of time before a mistake will occur.’’
Wrong-patient procedures are serious mistakes, and can lead to death. The shock of losing a perfectly healthy kidney is something few can imagine. Data from states with mandatory reporting laws seem to demonstrate that wrong-patient procedures happen 40-60 times a week. However medication errors are far more common than wrong-patient procedures, as medication is prescribed more than procedures are carried out, raising the odds. In one study, despite the fact that all wrong-patient medication errors were caught, the volume of incorrect orders that were placed was enormous: 5,246 wrong-patient electronic medication orders in on year at Montefiore Medical Center in New York City according to a 2013 study.
It’s clear that patient misidentification breeds ample opportunities for patient harm through simple errors, whether because of medication or unnecessary procedures. If you or a loved one has been harmed in a wrong-patient procedure or through incorrect medication caused by misidentification please contact the attorneys at Parker Scheer for a free and confidential consultation.