Cases & Commentaries

Moved Too Soon

Commentary By Peter Lindenauer, MD, MSc

The Case

A 67-year-old man was admitted to a general
hospital ward after undergoing a laminectomy. Two hours after
arriving, while the patient was still groggy from anesthesia, a
nurse entered the room and stated that it was time to administer
his clonazepam. As the patient began to take the medicine, his
daughter (who happened to be a nurse) stated that she didn't think
he should be receiving clonazepam and asked the nurse to double
check prior to administration. The nurse returned after checking
and asked, "Aren't you Mr. X?" The patient said, "No, I am Mr.

It turned out that, due to a bed shortage, Mr. J
was to be moved down the hall, and Mr. X, a seizure patient
scheduled to be transferred out of the neuro-ICU that afternoon,
was to be moved into that room. The room change was made on the
hospital's computer before the patients were physically moved.
Thus, when the nurse checked the computer, it showed that Mr. X was
in that room and due for his clonazepam.

The Commentary

This near miss provides a
classic example of patient misidentification, made worse by the
fact that a sophisticated computer system expected to prevent such
errors likely contributed to its occurrence.

The proper identification of patients during
hospitalization continues to challenge hospitals, evidenced by
JCAHO making improved identification a patient safety standard in
the last several years.(1) A
recent analysis of a voluntary near miss and event reporting system
shared by 54 neonatal intensive care units in the United States
found that 11% of cases involved patient misidentification
and wrong patient incidents accounted for 4% of all medication
During a recent 3-year period, the Veterans Affairs National Center
for Patient Safety received more than 100 patient misidentification
root cause analyses, 22% of which involved cases of medication

Tempering Expectations for
Information Technology

Increasingly, information technology is seen as a
solution to many patient safety issues facing our health care
While research on the benefits of CPOE and clinical decision
support systems give reason to be hopeful (6,7), qualitative studies have found that such systems
often precipitate new errors.(8) Not
only can the intrinsic design of hardware and software promote
error, but so too can the environments within which they are
deployed. As this case demonstrates, expectations about the
benefits of information technology should be tempered by a
recognition that human processes also play a critical role in
determining whether a particular technological "solution" will
succeed or fail. If human factors are
overlooked in planning, information technology may automate a bad
practice or accelerate the occurrence of errors.

One in a Series of

In this example, as in most such cases, a series
of errors occurred in the process of care which, had it not been
for a savvy family member, surely would have resulted in the wrong
medication being administered to this patient.

The first and most obvious error was that the
patient's location was changed in the computer system before the
patient had actually arrived at his new destination. Next, the
nurse failed to correctly identify the patient when she began the
medication administration process. Upon first entering the room,
the nurse did not ask his name, nor examine his wristband in search
of two unique identifiers. Upon reentering, the nurse asked a
closed-ended question ("Aren't you Mr. X?")—a passive method
of identification that is especially problematic when dealing with
young children, adults with dementia or delirium, or other language
or communication barriers. A better approach would have been to ask
an active question such as "What is your name?"(9)

Bar Coding and Radiofrequency

Ubiquitous in both supermarket checkout aisles
and in hospital materials management departments, bar coding is
finding new applications in patient care.(Figure 1) A bar code medication administration
process, in which nurses scan a medication, the patient for whom it
is intended, and then themselves, has obvious advantages over one
that relies on human vigilance to reconcile data on a medication
label and a patient wristband. Bar coding systems offer other
advantages, including being able to evaluate the appropriateness of
the timing of a given dose and eliminating the documentation
required to create a medication administration record. As in the
case of CPOE, the number of hospitals that have successfully
implemented bar coding into the medication administration process
is small in comparison to those that are planning or in the process
of implementation. It is now widely believed that Radio Frequency
Identification (RFID) will one day replace bar coding as a method
to safeguard the medication administration process. The primary
advantage of RFID is that the combination of a radio transmitter
and receiver eliminates the cumbersome process of scanning. RFID
tags can be read at distances up to several feet, while in motion,
in any orientation, and through intervening objects.

Could this error have occurred if the hospital
had a bar code medication administration system? While evidence
supporting the benefits of such systems remains limited (10),
bar coding has been advocated by many national organizations and
has received further support by a recent FDA decision to require
bar codes on most prescription medications within the next two
Unfortunately, but perhaps unsurprisingly, reports from early
adopters have identified a number of unintended effects of bar
coding that have led to new kinds of medication errors.(12)
Moreover, wristbands are not foolproof.(13) Thus, while bar coding may eliminate many wrong
patient or wrong medication errors, the reality is that nurses will
continue to play an important role in correctly identifying

Operationalizing Patient
Identification Standards

While bar coding could be considered in the
intermediate term, several short-term approaches can reduce the
occurrence of adverse events from misidentification. JCAHO
recommends using at least two patient identifiers when taking blood
samples or administering medications or blood products. Education
regarding the "5 rights" in medication administration (Right
patient, Right time and frequency of administration, Right dose,
Right route of administration, Right drug) is a fundamental element
of nursing training. At our institution, these lessons are
reinforced by highlighting actual cases reported to our own near
miss and event reporting system. Measurement and feedback is
another effective method of improving performance, and we
incorporate direct observation of medication administration into
the annual review process for nurses. Moreover, aggregated data are
presented and discussed at our monthly Nursing Practice committee

Whether dealing with a computer system used for
tracking patient location, or a simple dry erase board, the
hospital should also redesign the current process for initiating
and activating location changes, so that these changes are made
only when the patient physically arrives in the new location. While
not entirely clear from the case presentation, it's possible that
the tracking system allowed a patient location change to be made in
an already occupied bed. If this was so, the hospital should also
work with its software vendor to develop a forcing function
in its computer system to prevent such an occurrence. Such a
feature (Figure
) would send a warning to the user and prohibit such actions
from being completed.

Peter Lindenauer, MD,
Division of Healthcare Quality
Baystate Health System
Assistant Professor of Medicine
Tufts University School of Medicine


1. 2005 National patient safety goals. Joint
Commission on Accreditation of Healthcare Organizations Web Site.
Available at: [ go to related site ]. Accessed September 16,

2. Suresh G, Horbar JD, Plsek P, et al. Voluntary
anonymous reporting of medical errors for neonatal intensive care.
Pediatrics. 2004;113:1609-18.[ go to PubMed ]

3. Bates DW, Boyle DL, Vander Vliet MB, Schneider
J, Leape L. Relationship between medication errors and adverse drug
events. J Gen Intern Med. 1995;10:199-205.[ go to PubMed ]

4. Mannos D. NCPS patient misidentification
study: a summary of root cause analyses. National Center for
Patient Safety TIPS. Available at: [ go to related site ]. Accessed September 16, 2004.

5. Kohn LT, Corrigan JM, Donaldson MS. To err is
human: building a safer health system. Washington, D.C.: National
Academy Press; 2003.[ go
to related site

6. Dexter PR, Perkins S, Overhage JM, Maharry K,
Kohler RB, McDonald CJ. A computerized reminder system to increase
the use of preventive care for hospitalized patients. N Engl J Med.
2001;345:965-70.[ go to PubMed ]

7. Bates DW, Leape LL, Cullen DJ, et al. Effect
of computerized physician order entry and a team intervention on
prevention of serious medication errors. JAMA. 1998;280:1311-6.[ go to PubMed ]

8. Ash JS, Berg M, Coiera E. Some unintended
consequences of information technology in health care: the nature
of patient care information system-related errors. J Am Med Inform
Assoc. 2004;11:104-12.[ go to PubMed ]

9. Campbell D. Listen to the family. AHRQ
WebM&M [serial online]. June 2004. Available at: [ go
to related commentary ]. Accessed October 14, 2004.

10. Wald H, Shojania KG. Strategies to avoid
wrong-site surgery. In: Shojania KG, Duncan BW, McDonald KM,
Wachter RM, eds. Making health care safer: a critical analysis of
patient safety practices. Rockville, MD: Agency for Healthcare
Research and Quality; 2001: 494-500. AHRQ publication 01-E058.
Evidence report/technology assessment. no. 43. Available at: [
go to related site ]. Accessed September 16, 2004.

11. Food and Drug Administration. Bar code label
requirements for human drug products and blood. Fed Register.

12. Patterson ES, Cook RI, Render ML. Improving
patient safety by identifying side effects from introducing bar
coding in medication administration. J Am Med Inform Assoc.
2002;9:540-53.[ go to PubMed ]

13. Rosenthal MM. Check the wristband. AHRQ
WebM&M [serial online]. July 2003. Available at: [ go
to related commentary ]. Accessed September 23, 2004.


Figure 1. A Health Care Bar Coding System in

Figure 2. Forcing Function Prohibiting
Transfer to an Occupied Bed.