An 85-year-old Cantonese-speaking woman was
admitted to the medical service with altered mental status and a
reported fall. After finding tenderness in her left hip, the
physicians obtained plain films, which confirmed a nondisplaced
femoral neck fracture. The orthopedic surgery team was consulted
and, after evaluating the patient, decided that the patient's age,
comorbidities, and minimal pain and tenderness on exam made her a
candidate for conservative, nonsurgical treatment. These
recommendations were documented in her electronic health record,
where the team specifically noted: "We're reassured to see the
patient is able to weight-bear without pain, even though we
wouldn't suggest it in the short-term."
The following day, one of the medical interns
read the orthopedic surgeon's note and found these comments about
the patient ambulating odd. The patient had strict bed-rest orders
and was in significant pain, making it hard to believe that she had
been observed walking. After further investigation, the intern
realized that the orthopedic team had evaluated the wrong
patient—the patient's roommate, who also happened to be a
Cantonese-speaking elderly woman. The orthopedic surgery team was
consulted again and, after some embarrassment about their mistake,
offered surgical repair of the correct patient's fractured hip.
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Table. Comparison of Passive and Active
Communication Techniques for Confirming Patient
Physician: Good morning, Mrs. Jones. I'm sorry to awaken you. My
name is Dr. Brown, and I'm from the Orthopedic Department. Your
physician asked that I stop by to visit with you and briefly
examine you this morning.
Physician: Good morning; I'm sorry to awaken you.
Patient: That's okay.
Physician: My name is Dr. Brown from the Orthopedic Department.
Can I take a moment and ask you to confirm your name? [Looks at
Patient: I'm Sarah Jones.
Physician: And can you confirm your date of birth for me?
[Still looking at name band.]
Patient: March 4, 1936.
Physician: Thank you, Mrs. Jones. We always like to make sure
we're talking to the right patient before we begin to discuss
important medical information. Is this a good time to visit with
you about your recent fall and hip injury?
Patient: It's fine, doctor.
Figure. Example of patient wrist band using
patient name, date of birth, bar coding, and patient photo as aids
to proper patient identification.