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Related Experiment Videos

The wrong patient.

Mark R Chassin1, Elise C Becher

  • 1Department of Health Policy, Mount Sinai School of Medicine, Box 1077, 1 Gustave L. Levy Place, New York, NY 10029-6574, USA. mark.chassin@mssm.edu

Annals of Internal Medicine
|June 5, 2002
PubMed
Summary
This summary is machine-generated.

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Wrong-patient invasive procedures are underreported medical errors. A case review revealed multiple system errors, not single mistakes, caused a patient to undergo the wrong invasive electrophysiology procedure.

Area of Science:

  • Patient Safety
  • Medical Errors
  • Healthcare Systems

Background:

  • Wrong-patient invasive procedures are a critical yet underreported category of medical errors.
  • Existing literature lacks comprehensive discussions on these specific adverse events.
  • This study addresses the underreporting by examining a real-world case.

Observation:

  • A patient was mistakenly prepared for another patient's invasive electrophysiology procedure.
  • A root-cause analysis identified at least 17 distinct errors contributing to the event.
  • No single error was sufficient to cause the adverse outcome independently.

Findings:

  • The adverse event resulted from the interaction of multiple "active" errors with underlying "latent conditions" (system weaknesses).

Related Experiment Videos

  • Key system weaknesses included inadequate patient identification and informed consent protocols.
  • Systemic issues in information exchange among caregivers and team functionality were also identified.

    • Implications:

    • Highlights the need for robust protocols in patient identification and informed consent.
    • Emphasizes improving communication and teamwork within healthcare settings to prevent similar errors.
    • Underscores the importance of addressing systemic vulnerabilities to enhance patient safety in invasive procedures.