Medical errors: Negligence leads to patient mix-up

20161227150000, Teo Jun Hong
Neglecting to correctly identify patients can lead to harmful medical errors
Neglecting to correctly identify patients can lead to harmful medical errors
At least 14 cases of medical errors have occurred at health facilities in Massachusetts since 2011, of which at least ten were caused by failure of healthcare professionals to follow a simple rule: identifying a patient with their full name and date of birth.

The erroneous procedures include wrongly inserted intravenous catheters, endoscopies, and biopsies amongst others.

Hospital staff neglected to identify patients due to language barriers

Some of these patients did not speak English, and these instances may have further increased the risk of medical errors.
One incident involved two patients, identified as Patient 1 and Patient 2, both whom were from the same country and did not speak English, had similar birth dates and even had the same names.

Instead of calling for an interpreter, the hospital simply identified and registered Patient 1 as the other, and when he underwent a CT scan, the imaging, which showed positive changes of cancer, was sent to Patient 2’s doctor who promptly scheduled an ultrasound-guided biopsy for his unfortunate patient.

Unsurprisingly, the biopsy came back negative, and it was a second scan that revealed the error that had occurred.

If the mix-up was not surprising enough, inspectors who visited UMass Memorial to investigate the incident found that the records for both patients still contained swapped results – even though the error had already been identified weeks ago.

Unfortunately, while most would think that such errors are far and few between, many similar incidences have occurred in the hospital.

There was a patient who once received a certified letter with positive test results that was intended for another person, and another patient went for an X-Ray meant for someone else.

At Saint Vincent Hospital, a mix-up of patients with the same name led to an unnecessary removal of a healthy patient’s kidney. The error was only identified when a biopsy of the kidney showed no unusual findings.

Medical errors: Not as rare as we think

Authorities faulted the UMass Memorial and Saint Vincent Hospital for neglecting to carry out detailed investigations and enforcing plans to prevent repetitive incidences, and the Centers for Medicare and Medicaid Services warned a possibility of suspension from the federal Medicare program if situations did not improve.

The president of UMass Memorial Health Care Dr Eric Dickson defended in saying that he has informed hospital staff to adhere to procedures at all times, which included checking a scan immediately before carrying out a procedure, or asking a patient for two identifiers, such as their names and dates of birth, to match the information on the scan.

“If you fail to follow the procedures it’s only a matter of time before a mistake will occur,” he added.

Patients who are subjected to medical errors become victims to emotional trauma of misdiagnosis, physical harm and sometimes even death.

In a study involving over 7,600 voluntarily reported patient mix-ups by ECRI Institute, a patient safety research organization in Pennsylvania, hospital staff managed to identify most mistakes before harm was brought onto patients but two incidences resulted in the death of patients.

Regrettably, health care safety experts believe that medical errors are underreported by hospitals and health facilities.

According to Coleen Smith, director of high reliability initiatives from Joint Commission, data from areas with mandatory reporting laws reveal that errors involving wrong procedures, wrong patients or wrong body parts, occur up to 60 times a week, adding that medication errors were significantly more common as procedures are performed far less than drug prescriptions.

“Forty to sixty may seem like a lot but there are hundreds of thousands of procedures happening,’’ she stressed. MIMS

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Sources:
https://www.bostonglobe.com/metro/2016/10/13/hospital-removes-kidney-from-wrong-patient/B9znKaZEHNr8nN1AHY78SL/story.html
https://www.bostonglobe.com/metro/2016/11/20/right-procedure-wrong-patient/tyI86sU45hPmaVct8Us5AL/story.html