Annals of Internal Medicine: The Wrong Patient

What do you mean I'm scheduled for open heart surgery?

This is an interesting article I stumbled upon a few days ago. It's a quick read (only 8 pages) on research done regarding how complex healthcare organizations (hospitals) can make mistakes such as performing the wrong operation on the wrong patient. The study follows the case of two patients, Joan Morris and Jane Morrison, the former being a patient who was arranged to undergo a cerebral angiography but mistakenly underwent an invasive cardiac electrophysiology exam the next morning that was scheduled, in fact, for the latter. We might go, "How could they have not possibly seen that the patients' names, albeit somewhat similar, were not the same?" We also might go blaming the nurses, doctors, and even the patients who all seemingly suffered from a bad case of bad communication-itis in this case. But the study sheds light on how such an "obvious" mistake really isn't that obvious at all in practice. Throughout the study there were a total of seventeen discrete mistakes documented that were made within the time from when Morris was taken in for the study to the point where the staff realized that they had operated on the wrong individual. Ultimately the study demonstrates that it is the collective culmination of all these individual errors that led to the operation on the wrong patient, and that none of these mistakes by themselves could have resulted in such an error. The study further discusses lack of systematic protocol for admitting patients in some hospitals and how the "culture of low expectations" leads hospital staff to overlook the details that could have prevented such scenarios from happening. For the full study, go here.