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This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid.