AHRQ Patient Safety Network

Mistaken Identity AHRQ WebM&M icon

Hall LW. AHRQ WebM&M [serial online]. October 2008.

Orthopedic surgeons rounding on an elderly Cantonese-speaking woman recommend conservative, nonsurgical treatment for her broken hip, as their examination noted that the patient was able to walk. Given that strict bed rest orders were in place for this patient, a medical intern found the note peculiar. Further investigation revealed that the surgeons had actually walked the patient's roommate, another Cantonese-speaking woman.

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