Medical Error: Test done on the wrong patient

This is a true story

It happened to one of my patients about 10 or more years ago in a local community hospital.

The mistake: A nuclear liver scan was done on my patient without my order.

I received a call from the radiologist informing me that a liver scan was mistakenly performed on my patient and we have to notify the nuclear regulatory commission of this mistake.

I also informed the patient of the error and explain that no harm was done. I also apologized to the patient for the inconvenience and some pain caused by the intravenous injection of the radioactive material. The pain was caused by the insertion of the intravenous needle. The patient was very understandable.

How did this error happened? The transporter took the wrong patient. He or she was supposed to check the patient's ID and signed the patient out at the nursing desk. Apparently this transporter did not do that.

The clerk in the Xrays department did not identtfy the patient correctly. The xrays technician and the radiologist also did the same mistake by not double checking the identity of the patient.

In this case,the ultimate responsibility lied on the radiologist. If he had opened the chart he would have found out that I did not order a liver scan on this patient.

The scenario mentioned above can happen again and again due to human error even in the setting of a well written policy and procedure of avoiding the error like this.

How can you as a patient prevent this kind of error from happenning? By being inquisitive or in other words: speaking up. Feel free to ask any health care personnel what kind of test is going to be done on you. If you don't get a clear cut answer,call or have the nurse page your doctor to verify. In case of patient who can not make his or her own decision,this responsiblity of speaking up will be upon the guardin or care giver.

The physician's role is also important. The attending physician should always inform the patient verbally about any test to be done. The radiologist must make sure that there is a wriiten order for the test and identify the patient according to the written protocol.