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4 June 2002 | Volume 136 Issue 11 | Pages 826-833
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.
Author and Article Information
From Mount Sinai School of Medicine, New York, New York; and University of California, San Francisco, San Francisco, California.
*This paper was prepared by Mark R. Chassin, MD, MPP, MPH, and Elise C. Becher, MD, MA, for the Quality Grand Rounds series. Kaveh Shojania, MD, prepared the case for presentation.
Grant Support: Funding for the Quality Grand Rounds series is supported by the California HealthCare Foundation as part of its Quality Initiative.
Requests for Single Reprints: Mark R. Chassin, MD, MPP, MPH, Department of Health Policy, Mount Sinai School of Medicine, Box 1077, 1 Gustave L. Levy Place, New York, NY 10029-6574; e-mail, mark.chassin{at}mssm.edu.
Current Author Addresses: Drs. Chassin and Becher: Department of Health Policy, Mount Sinai School of Medicine, Box 1077, 1 Gustave L. Levy Place, New York, NY 10029-6574. ACADEMIA AND CLINIC
QUALITY GRAND ROUNDS
Series Editors: Robert M. Wachter, MD; Kaveh G. Shojania, MD; Sanjay Saint, MD, MPH; Amy J. Markowitz, JD; and Mark Smith, MD, MBA
The Wrong Patient
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