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Identification Errors
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MARCH 2012
Turn the Other Cheek
with commentary by John Starling III, MD
Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed.
JUNE 2011
Say it Again
with commentary by Kerm Henriksen, PhD; Kendall K. Hall, MD, MS
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
JUNE 2011
The ECG is Not Normal
with commentary by Abigail Zuger, MD
An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.
NOVEMBER 2010
Mother's Milk, but Whose Mother?
with commentary by Dorothy Dougherty, RN
A hospitalized 2-month-old infant is fed breast milk from another infant's mother after the wrong bottle is pulled from the ward's refrigerator.
APRIL 2009
EMR Entry Error: Not So Benign
with commentary by Ross Koppel, PhD
A patient hospitalized with
Pneumocystis jiroveci
pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
OCTOBER 2008
Mistaken Identity
with commentary by Leslie W. Hall, MD
Orthopedic surgeons rounding on an elderly Cantonese-speaking woman recommend conservative, nonsurgical treatment for her broken hip, as their examination noted that the patient was able to walk. Given that strict bed rest orders were in place for this patient, a medical intern found the note peculiar. Further investigation revealed that the surgeons had actually walked the patient's roommate, another Cantonese-speaking woman.
JULY/AUGUST 2007
Mark My Tooth
with commentary by Richard A. Smith, DDS
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
DECEMBER 2006
Right Patient, Wrong Sample
with commentary by Michael Astion, MD, PhD
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.
MAY 2006
Right? Left? Neither!
with commentary by Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH
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.
DECEMBER 2004
Overriding Considerations
with commentary by Neil A. Holtzman, MD, MPH
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.
DECEMBER 2004
Mark My Limb
with commentary by Dennis S. O'Leary, MD; William E. Jacott, MD
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
OCTOBER 2004
Moved Too Soon
with commentary by Peter Lindenauer, MD, MSc
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.
JULY 2004
Allergy to Holter
with commentary by Mark V. Williams, MD
A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.
JUNE 2004
Listen to the Family
with commentary by Darrell Campbell, Jr., MD
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.
FEBUARY 2004
Transfusion "Slip"
with commentary by Harold S. Kaplan, MD
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.
JANUARY 2004
To Resuscitate or Not?
with commentary by Albert W. Wu, MD, MPH; Peter J. Pronovost, MD, PhD
A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error.
OCTOBER 2003
Urine a Tough Position
with commentary by Tejal K. Gandhi, MD, MPH
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
JULY 2003
Check the Wristband
with commentary by Marilynn M. Rosenthal, PhD
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.
FEBUARY 2003
Patient Mix-Up
with commentary by Kaveh G. Shojania, MD
A man almost received a medication intended for another patient with the same last name in the same room.