A man went into the hospital for prostate surgery. It was a straightforward surgery and he should have done well. He was otherwise healthy. He was accidentally wheeled into the wrong room. A physician came into the room holding the wrong chart and started talking to the patient. He explained that he had cancer and heart disease, and provided the equivalent of death counseling. The patient died that night of a heart attack.
This story told by Tony Robbins on his Live with Power CDs.
A woman was wheeled into the operating room for a diagnostic laparoscopy to find out why she could not become pregnant. The surgeon did not pay attention to her name, and thought she was someone else. He performed a tubal ligation, making sure that she would not be able to become pregnant.
This case was one in which Med League supplied an operating room expert witness.
A couple of patient transport aides came to a nursing unit recently and put a patient on a stretcher to go down for neck surgery. The nurse standing in the hallway asked why they were there. She had listened to change of shift report and knew that patient was not scheduled for surgery. She had to insist the transporters, who were arguing with her, that they were taking the wrong patient. They had not checked the patient identification.
This story was shared with me by the staff nurse involved in stopping the transporters.
A woman with breast cancer received a letter from the hospital billing department that she was being treated for thyroid cancer. The woman believed her cancer had spread and hysterically called her daughters to come to her side. When her family did more investigation, they found out the billing clerk had looked at the wrong medical record – another patient had thyroid cancer.
This story was told by one of my employees, who left work to be with her crying mother.
The first three cases occurred in hospital settings where patients should always have an identification band on. If swelling prevents use of a wrist band, it should be pinned to or attached to the patient’s gown in some other way. The patient should be identified with two pieces of data – a name band, a birth date, a name – or some other way. The room number is never to be one of the pieces of data since it can easily change.
In the last case, when I heard about this letter, I asked my employee if it was possible there was a mistake. It did not seem right that the patient would find out through a letter that she had thyroid cancer.
What you can do
• Remember the expression about computers: “Garbage in, garbage out”? It means that if you feed poor quality information into a computer, you’re going to get poor quality information out. Computers can make errors. Healthcare providers are not perfect. They make mistakes.
• Don’t switch off your critical thinking when you hear health news. Filter it through a questioning process. Does this make sense? Is it consistent with what you already know about yourself? Have other people told you about this same health issue?
• Does the diagnosis make sense in terms of your symptoms? I know you’re thinking that some of this is way beyond your knowledge as a patient, and you can’t be expected to second guess every medical diagnosis. That is true, but you can question, research, and get a second opinion.
• If you are a patient, make sure every person who is doing something to you confirms your identity first. This is a critical patient safety step that should never be skipped. It is particularly important before you receive medications, go for tests, have blood work done, or any other invasive procedure.
Have you ever gotten healthcare information about yourself that you questioned? Have you ever been misidentified by a healthcare provider? Share your story.