Medical mistakes

Medical mistakes happen. You’ve heard the stories of people having the wrong body part surgically removed, getting misdiagnosed because vials were mislabeled at the lab, or a pharmacist filling the pill bottle with the wrong medications. Medical mistakes are all too common and they kill about 100,000 people a year.

I am not the type of doctor that performs surgery or prescribes medicine, but today I was involved in a situation in which a serious medical mistake was almost made. I was called to evaluate an inpatient on one of the medical units. When I arrived, the patient was not in her room. This can mean several things: the person has been moved to another floor, the person is off the floor for tests, or the person is somewhere else on the floor.

So I asked two staff members where the patient was. They pointed to someone sitting by a telephone and said that was her. Now, I always check the wrist identification bracelets to avoid identification mix-ups, but this patient didn’t have one, which was frustrating. So I asked her if she was the patient I was looking for and she said she shared the first name but reported a different last name.

It’s important to keep in mind here, that the patient I was looking for had a known psychotic condition. So when she said her last name was different, that is something that can occur in psychosis. It’s called a delusion. Nevertheless, I went to the same staff members and double-checked: “Are you sure this is the same person because she is saying she is someone else?”

“Oh yes” was the reply I got, “She does that. It’s part of her psychosis.” So I took the person into her room to do the interview and before I did, I triple checked her identity with another staff member. “Yep, that’s her” was what I was told. So I finished my evaluation and walked out. As I left, I ran into the referring physician and started describing some of the things the patient was telling me. I was met with odd looks and he could not believe I was talking about the same person.

Turns out, all three staff members identified the patient incorrectly because two patients had similar sounding first names on the unit. I said the last name when I asked for the patient, but all the staff focused on was the first name.

If I didn’t bump into the referring doctor when I left the unit, I would have generated a completely wrong report. He was naturally upset with the staff and questioned why on Earth the patient did not have her identification bracelet on. Mistakes are always going to happen I suppose. Good thing this one was caught before anything serious happened.
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