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Perspectives on Safety > Interview
New Insights on Safety and Health IT, July/August 2015
Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
Cases & Commentaries
- Spotlight Case
- Web M&M
John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM; July/August 2015
A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error.