The Wrong Patient

A 67-year-old woman admitted to a teaching hospital for cerebral angiography mistakenly underwent an invasive cardiac electrophysiology study on the wrong patient, representing one of the most disturbing errors of all of the errors made in delivering health care.

Abstract

Among all types of medical errors, cases in which the wrong patient undergoes an invasive procedure are sufficiently distressing to warrant special attention. Nevertheless, institutions underreport such procedures, and the medical literature contains no discussions about them. This article examines the case of a patient who was mistakenly taken for another patient's invasive electrophysiology procedure. After reviewing the case and the results of the institution's "root-cause analysis," the discussants discovered at least 17 distinct errors, no single one of which could have caused this adverse event by itself. The discussants illustrate how these specific "active" errors interacted with a few underlying "latent conditions" (system weaknesses) to cause harm. The most remediable of these were absent or misused protocols for patient identification and informed consent, systematically faulty exchange of information among caregivers, and poorly functioning teams.