WebM&M: Case Studies

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.

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

A patient was mistakenly administered intravenous fentanyl which was leftover from a previous patient and not immediately wasted. Experts recommend the best practice for the safe disposal, or “waste”, of medications in the surgical setting is to either waste any leftover product immediately after administration or to fully document all waste at the end of the case.This commentary discusses the policies and procedures addressing wasting of medication by anesthesiologists, approaches to reduce medication administration errors, and the importance identifying process gaps that could lead to potential diversion.  

The patient safety committee at a large tertiary care hospital received nine incident reports within three months involving electrocardiogram (EKG) reports that were uploaded into the wrong patients’ chart. All of these events were due to users failing to clear the previous patient’s information from, and/or users failing to enter the new patient’s information into, the EKG machine when obtaining an EKG.

This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.

Multiple patients were admitted to a large tertiary hospital within a 4-week period and experienced patient identification errors. These cases highlight important systems issues contributing to this problem and the consequences of incorrect patient identification.

Two patients arrived at the Emergency Department (ED) at the same time with major trauma. Both patients were unidentified and were given "Doe" names. Patient 1 was quickly sent to the operating room (OR) but the ED nurse incorrectly gave him Patient 2's "Doe" name. The OR nurse only realized there was a problem when blood arrived with Patient 1's correct "Doe" name, requiring multiple phone calls with the ED, laboratory, and surgeon to correctly identify the patient.

A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.

A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.

Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.

A pregnant woman is offered genetic testing for herself and her husband. Although he declines, the next time he undergoes routine testing, the phlebotomist overrides the consent in the computerized record and runs the test anyway.

A surgical patient and a neurosurgical patient are scheduled to be moved to different beds, the second taking the first's spot. However, the move is documented electronically before it occurs physically, and a medication error nearly ensues.

A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.

Despite persuasion from a surgical resident that her mother's life was in danger, a patient's daughter refuses consent for surgery on her mother. This was wise, since the procedure was intended for a different patient with the same unusual surname.

Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake.

Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.

An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.

A man almost received a medication intended for another patient with the same last name in the same room.