Please help with this assignment. Strictly follow the attached rubric and address each topic.

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.

Data Analysis

Chassin and Becher note that 17 active errors contributed to the misidentification of the patients and surgery on the wrong patient. The timeline, Figure 5.10, is invaluable in understanding the sequence of events as well as the dynamics of the situation. Figure 5.10 Timeline of Events From Chassin and Becher’s chronology of events, it is clear that the initial error occurred when an unknown telemetry staff member mistakenly informed electrophysiology that the scheduled patient had been transferred to oncology when the patient was still on the unit. The initial misidentification began a cascade of errors but was insufficient by itself to result in surgery on the wrong patient. Multiple individuals, including physicians and nurses, failed to correctly identify the patient. Care givers were unreceptive to the patient’s objections to the procedure as well as undeterred by the lack of documentation to support the procedure. Multiple warning signs were ignored and a number of individuals had the ability to recognize the patient identification error before the procedure had been in process for more than an hour. The identification of latent errors shifts gears and examines the features of the system that contributed to the error. Were there systemic reasons why after the initial misidentification subsequent care givers did not recognize that the patient transferred to, prepared for, and undergoing a procedure was not the correct patient? In identifying latent errors, the concern is less with the actions taken or not taken than with why these actions occurred or did not occur. In this case, the actors and actions are known. But if other people had been involved, would the outcome have been different? Answering this question requires understanding organization practices and the larger health care delivery system. Health care delivery is built on professional sovereignty, clear lines of authority, specialization, and teamwork. The sovereignty and authority of physicians is based on their competence and ability to select the best course of treatment for patients as well as to monitor the quality of care provided. The downside of professional sovereignty, specialization, and authority is that the health care industry has not developed fail-safe communication, monitoring, and accountability systems. The need for teamwork and faith in the ability of others, in this case and other cases, results in an unwillingness to question the actions of other health care providers. Poor communication was a systemic problem between staff and nurses, nurses and other nurses, nurses and doctors, and doctors and doctors. Although the patients’ names were similar, the event progressed without anyone recognizing the difference. A second problem was that much of the communication regarding the patient was transacted without using the patient’s name. A third systemic problem was the willingness of staff to proceed without proper documentation. The lack of written orders or informed consent was not seen as a red flag but simply something to be worked around. This speaks to the fact that many organizations have policies, such as documentation requirements, that have little impact on day-to-day processes. Fourth, once the process was set in motion, there was a reluctance to stop it despite a dearth of information. This may be the result of an unwillingness to fall behind schedule, overconfidence in the abilities of coworkers, or complacency with the process. In many organizations, standard operating procedures rise to such a high level of regard that employees do not want to be seen as upsetting the system instead of focusing on their duty to protect the interests of their patients. Finally, the case shows this institution had no standardized patient identification protocol. The authors concluded that environmental pressures contributed to the error; that is, reduced staffing, the desire for rapid treatment and discharge, and increasing subspecialization put more emphasis on getting things done and undermined a more deliberative approach to care. The major systemic problems appear to be lack of sensitivity toward patients, poor communication, overconfidence in the abilities of others, and an expectation that system deficiencies were common and should be worked around.

Implementing Corrective Action

After this incident, the organization mandated that multiple patient identifiers be checked prior to care. The emphasis on ensuring the correct identity of the patient (verification) is valuable; care givers should not assume they have the correct patient. Will multiple identifiers correct the problem? The problem was not that two identifiers needed to be checked, but that care givers did not check a single identifier, the patient’s name, after the initial misidentification occurred. A second problem is the inability of enforcing this policy. Will hurried professionals check a second identifier when they have verified one? Probably not. Will hurried professionals indicate that they have checked two identifiers for documentation purposes but only review one? Probably. The second corrective action implemented appears to be more substantial. A policy was promulgated that no transport was to take place without a signed order. This places informational, measurement, and natural safeguards into the system. The informational safeguard is the order, the measurement safeguard is verification of another party, and the natural safeguard is the time (time-out) imposed on action by this requirement.

References

Chassin MR, and Becher EC, 2002, The Wrong Patient, Annals of Internal Medicine 136 (11): 826–833

Gray JE, Suresh G, Ursprung R, Edwards WH, Nickerson J, Shiono PH, Plsek P, Goldmann DA, and Horbar J, 2006, Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk, Pediatrics 117 (1), e43–e47.