A Case of Mistaken Identity: The Importance of Interdisciplinary Communication in the Discharge Process

Effective communication is a critical component of quality health care. In the setting of hospital admissions, communication among patients and the health care team is necessary for all stages of treatment, including discharge planning. Communication includes delivering relevant health information, discussing available options for continued care, and eliciting the patient's choices. The following case discussion describes a lapse in provider-patient communication that resulted in ruptured rapport and delayed discharge. Specifically, we reflect on a case in which a patient was erroneously identified as a registered sex offender, including the communication errors that stalled clarification of this misinformation, hindered eligibility for placement at appropriate care facilities, and ultimately delayed a timely hospital discharge. Discussion includes consideration for (a) the role of context and diffusion of responsibility, (b) stigma and unconscious bias, and (c) lack of standard operating procedure for information regarding criminal justice involvement. We conclude with recommendations for improving practice.