“Patient identification (ID) errors can disrupt care and harm patients in virtually every facet of clinical medicine, including diagnostic testing, medication administration, and even billing.” – ECRI Institute
CAMDEN, N.J. (AP) — A New Jersey hospital says a kidney meant for one patient was mistakenly transplanted into another with the same name who was farther down the priority list.
Virtua Health says the Nov. 18 operation on a 51-year-old patient at Virtua Our Lady of Lourdes Hospital in Camden. was successful.
But officials then discovered the patient was given the kidney out of priority order because “unusually, the individual who should have received the organ has the same name and is of similar age.”
Virtua Health says the error was reported to state health officials and the Organ Procurement and Transplantation Network.
The patient who should have received the kidney also underwent a successful transplant on Nov. 24.
Officials say steps have been taken to prevent it from happening again.
[In this particular case, no harm was done because both patients with the same name needed the same operation. However, a recent ECRI report found that nearly 9% of patient ID errors resulted in harm. The lesson is clear – you, the patient, need to protect your own health in any medical setting by insisting that all staff members properly identify you before performing surgery or administering drugs. – Ed.]
“Notably, one Canadian study found that during surgery, wristbands were often inaccessible or removed, posing risks for this vulnerable population both [during and after surgery].” – ECRI Institute
Examples of serious adverse events from patient misidentification included:
- A patient was not resuscitated in the operating room because doctors pulled up the wrong health record, which included a do-not-resuscitate order
- A patient who was not supposed to eat but was brought the wrong meal tray and nearly choked
- A patient who was given another’s hypertension medication at 10 times the normal dose
- An infant who was infected by hepatitis after being given breast milk from the wrong mother. Source.
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