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Wrong Catheter in the Right Patient

Catherine Chia, MD and Mithu Molla, MD, MBA | May 27, 2020
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The Case 

A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had two peripheral intravenous (IV) lines that infiltrated while he was receiving intravenous antibiotics with high dose steroids. When a third IV line also infiltrated, the nurse caring for the patient that night called the attending physician and asked for permission for peripheral intravenous central venous catheter (PICC) placement. She received a telephone order to place an interventional radiology (IR) consult for PICC insertion to be scheduled as soon as possible.   

With the next shift change, a new team took over and after a few hours, the IR nurse called asking for a pre-procedure checklist. The IR nurse was given basic information including the patient’s vital signs and hemodynamic parameters. Within 30 minutes, the patient was wheeled down, the procedure was completed uneventfully, and the patient returned to his room. When the unit nurse came in to assess the patient, the physician walked in at the same time and both were surprised to see that a tunneled dialysis catheter (TDC) had been placed instead of a PICC line.   

On review of the electronic health record, it was found that the order had been entered for a TDC instead of a PICC by the night nurse who had taken the verbal order from the physician. During the shift change that morning, the sign-out to the day shift nurse indicated that PICC insertion had been arranged. The day shift nurse called to confirm the procedure without realizing that a wrong order had been placed. Unfortunately, since the pre-procedure checklist did not specify the need for a PICC, the physician placed a TDC instead. After the error was recognized, the IV team was called to place a midline catheter into the basilic or cephalic vein to give IV antibiotics. This plan was immediately explained to the patient as well. After all safety checks were completed, the dialysis catheter was removed without any untoward consequence to the patient.  

The Commentary

By Catherine Chia, MD and Mithu Molla, MD, MBA 

There are two broad areas in which quality gaps were identified in this case.  In our commentary, we focus on those areas: 1) use of verbal orders, and 2) policies and practices regarding procedures. 

Verbal Orders

Verbal orders (VO) include all telephonic and face-to-face patient care orders that are communicated verbally by an ordering provider. These orders are then either transcribed on paper or entered electronically by the person receiving the order, followed by a provider signature at a subsequent time to validate the order. Verbal orders are an important tool that can help expedite care by allowing a proxy to enter orders when a provider is unable to do so.  For example, the use of a VO may be necessary during emergent patient care situations, sterile procedures, or when remote access to the electronic health record (EHR) is limited.  Nonetheless, VOs inherently come with risks of miscommunication or mistranscription, and should be a target for hospitals seeking to improve patient safety practices.

Although it is commonly accepted that there are risks associated with VOs, published data on this issue are limited, consist primarily of anecdotal evidence, and may not be relevant to current practice.1-3 The literature regarding VOs that does exist addresses mainly errors related to medication orders and pre-dates the widespread use of EHR with computerized provider order entry (CPOE). While only 13% of a random sample of U.S. healthcare facilities had a fully implemented EHR by 2004,4 84% of non-federal acute care hospitals had such a system by 2015.5 Access to CPOE has allowed providers to place orders directly from their offices or homes. Institutions hoped to leverage this technology to reduce verbal order use and prevent medication prescribing errors through embedded safety alerts. However, a survey conducted by the Institute for Safe Medication Practices in 2017 indicated that for about one quarter of 1,622 respondents, including nurses, pharmacists, and other practitioners in a variety of hospital settings, about 25% of all orders were still given verbally.6 As problems with verbal orders have persisted despite the shift from handwritten to electronic orders due to VO characteristics and inconsistent verification techniques, effective methods for safely using VOs are essential.6   

Approach to Improving Safety

When analyzing errors that stem from the use of verbal orders, the context as well as the content of the order should be examined. Context refers to the conditions or circumstances under which a verbal order is given, and the processes used to communicate, verify, and transcribe the order. Content refers to the number and type of order being communicated. Examples of different VO content characteristics include order complexity, order urgency, abbreviations and non-standard terminology, and the use of sound-alike drugs and/or doses along with high-alert medications.7 

In this particular case, the VO context is not completely clear. The nurse who received the verbal order was working during a night shift. A number of environmental and human factors may have contributed to the initial order entry error. For example, nurses are often interrupted or distracted when performing complex tasks such as taking and entering verbal orders. If the telephone call occurred at the end of the shift, the nurse might have been fatigued, especially with a high-acuity patient load. If the nurse had limited experience placing procedure orders, the distinction between a PICC and a TDC might have caused confusion.

To limit some of the contextual factors that can contribute to errors, The Joint Commission developed a standard that requires verbal orders to be recorded and “read back” to the authorizing provider.8 Clinicians receiving verbal orders should transcribe the order directly into the medical record or order entry system, read back the order, and confirm they understand the indication for the order. This helps ensure that one has heard and transcribed an order correctly. Despite this standard, surveys have indicated that nearly half (45%) of all those who receive telephone or face-to-face verbal orders adhere to this standard less than 50% of the time. Sixteen percent of respondents to one survey reported that they read back verbal orders only 1% to 5% of the time, and 9% indicated they never carry out this important verification process.6 

In terms of VO content, organizational policies can be helpful in placing restrictions on specific types of verbal orders, thereby decreasing risks of patient harm. Some examples include prohibiting verbal orders for high-risk medications such as chemotherapy agents, or for entire order sets, or for multiple orders given at one time. Arguably, a VO for any invasive procedure such as PICC or TDC placement could be considered complex or of high risk for patient harm if ordered inappropriately. In addition to adopting or updating restrictive VO policies, organizations can establish order sets for complex interventions that would allow providers to quickly place orders directly using CPOE rather than relying on a VO.

Eliminating VO use entirely could seem like the obvious solution, but this may be impractical even with remote EHR access. Many providers in community settings engage in daily on-site patient care and overnight coverage from home. The increasing complexity of patient care and demand on providers to multi-task also contribute to the ongoing use of VOs. Given their continued role in medicine, institutional guidance on acceptable uses for VO, methods for clear VO communication, direct transcription into the medical record, and compliance with the read back process for verification is necessary to safely utilize them.6 The first systematic review of organizational strategies and policies designed to ensure appropriate VO practices concluded there was “widespread, but not unanimous adoption” of Joint Commission standards in 2010.2 At that time, additional research on the incidence of near misses, adverse events and/or patient harm related to VO errors, the impact of CPOE implementation on VO policies and practices, VO policy compliance, and evidence-based VO best practices was still needed.2  Since 2010, literature providing new data has been sparse. 

Policies and Practices Around Procedure Orders

Once an order for a procedure has been placed in a CPOE system, there are some important questions to consider: Does it need to be verified? Who should take ownership for verifying the order? (For example, pharmacists assess the dose, route, and indication for medication orders and radiology technologists may review imaging orders for completeness.)  What does this verification process for procedure orders entail, and is simply reviewing the order enough?

Approach to Improving Safety

The Universal Protocol to prevent wrong site, wrong procedure, and wrong person surgery was created by the Joint Commission to address the occurrence of these medical errors. The Protocol became effective July 1, 2004 for all accredited hospitals, ambulatory care, and other office-based surgery facilities. The three key components of the Protocol include: having a preoperative verification process, marking of the operative site, and conducting a “time-out.”9 The preoperative verification process seeks to address missing information or discrepancies before starting the procedure, i.e. the correct procedure, correct patient, and correct site. Relevant documentation includes the case history, physical examination, signed consent form, and pre-anesthesia assessment. Diagnostic and radiologic test results, as well as any required blood products, implants, devices, and special equipment needs, should be identified.9 Scheduling mistakes can be identified by cross-checking with the physician’s plans in the patient’s history and physical. However, this level of verification may not be required by institutional policy.10

Adhering to the Universal Protocol would have provided three different opportunities to prevent the patient in this case from undergoing the incorrect procedure. First, while the existence of a procedure order was verified as part of a pre-procedure checklist, the procedure ordered did not match the patient’s clinical situation. The intent of verification processes is to allow for a deliberate assessment of the procedure type and indication in the context of the patient’s medical history. Additionally, unlike verification for medication or imaging orders, the standard protocol for verifying procedures includes review of the patient’s history and physical by the proceduralist who obtains patient consent; these steps serve as opportunities to identify discrepancies.

Application to Interventional Radiology

Apart from the Universal Protocol, other strategies to consider are direct communication between the ordering provider and proceduralist, or formal consultation as would be done with any specialist. For most patients requiring invasive procedures in a hospital setting, consultation with the service performing the procedure provides specialty guidance and can assist with clinical decision-making. Inventional radiology is unique in that a variety of procedures may be requested for a patient using EHR orders alone. As a procedure-based subspecialty established in the 1980s, IR has been transitioning to a more clinically focused care delivery model that includes collaboration with referring providers to select the appropriate procedure and active engagement in patient care before and after interventional procedures.11 In the Global Consensus Statement Defining Interventional Radiology, the clinical scope and practice of IR includes evaluation and management, patient consultation, treatment planning, and follow-up.12 Although the resources to support these best practices vary across facilities, verifying the indication for a requested procedure is clearly within the scope of an interventional radiologist and a responsibility of all proceduralists. In this case, a brief discussion or exchange of messages between the radiologist and the referring provider would have prevented the error.

Take-Home Points

  • Verbal orders are appropriate in certain settings, but improved compliance with best practices is necessary.
  • To prevent verbal order errors, enter orders directly into the medical record or CPOE system as they are being received and use the read back method to ensure accuracy.
  • Organizations should implement policies that limit types of verbal orders at high risk for patient harm and explore strategies for reducing the need for verbal orders.
  • The Universal Protocol consists of three components: preoperative verification, marking of the operative site, and “time-out;” these principles should be applied to all procedures.
  • All members of a care team should share responsibility for understanding and verifying the indications for a procedure. 


Catherine Chia, MD
Assistant Clinical Professor

Department of Internal Medicine, Division of Hospital Medicine

UC Davis Health

Mithu Molla, MD, MBA
Clinical Professor

Department of Internal Medicine, Division of Hospital Medicine

UC Davis Health

Acknowledgements: The authors acknowledge the contribution of Amy Doroy, RN, PhD for her input regarding the nursing care in this case.



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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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