The Wrong Patient By: Mark R. Chassin and Elise C. Becher

Summary of Events Joan Morris (a pseudonym) is a 67-year-old woman admitted to a teaching hospital for cerebral angiography. The day after that procedure, she mistakenly underwent an invasive cardiac electrophysiology study. The patient, a native English speaker and high school graduate whose daughter is a physician, had been well until several months earlier, when she fell and struck her head. Magnetic resonance imaging showed two large cerebral aneurysms. The interventional radiology service admitted her for cerebral angiography. The day after admission, cerebral angiography was performed, and one of the aneurysms was successfully embolized. The second aneurysm was deemed more amenable to surgical therapy, for which a subsequent admission was planned. After angiography, the patient was transferred to the oncology floor rather than returning to her original bed on the telemetry unit. Discharge was planned for the following day. The next morning, however, the patient was taken for an invasive cardiac electrophysiology study. Approximately 1 hour into the procedure, it became apparent that Ms. Morris was the wrong patient. The study was aborted, and she was returned to her room in stable condition. Chronology of Events Another patient, a 77-year-old woman with a similar name (Jane Morrison, a pseudonym) had been transferred from an outside hospital for a cardiac electrophysiology procedure and was also admitted to the telemetry unit. Ms. Morrison's procedure, which had been delayed for 2 days, was scheduled as the first electrophysiology case for the early morning of the day of Ms. Morris's planned discharge. 6:15 a.m. The electrophysiology nurse (RN1) logged on to the electrophysiology laboratory computer to check the morning schedule and saw Jane Morrison listed as the first case. (The electrophysiology laboratory's computer system is separate from the main hospital system and does not exchange information with it). RN1 telephoned the telemetry floor, identified herself by name, and asked for "patient Morrison" (giving no other identifying information). The person answering the telephone (never identified) incorrectly stated that Ms. Morrison had been moved to the oncology floor, when she was, in fact, still on the telemetry floor. 6:20 a.m. RN1 called the oncology floor, where Joan Morris had been transferred after her cerebral angiography. The person answering the phone mistakenly informed RN1 that the patient she sought (Jane Morrison) was there, and she was told that the patient would be transported to the electrophysiology laboratory. 6:30 a.m. Joan Morris's nurse, RN2, (who was nearing the end of her shift), agreed to transport the patient for the electrophysiology procedure, although neither the charge nurse nor Ms. Morris's nurse from the previous evening had told her of a plan for an electrophysiology procedure. RN2 assumed that the study had been arranged despite the absence of a written order for it in the chart. Ms. Morris stated that she was unaware of plans for an electrophysiology procedure, she did not want to undergo it, and she was nauseated. RN2 informed the patient that she could refuse the procedure after she arrived in the electrophysiology laboratory. 6:45 a.m. RN2 brought Ms. Morris to the electrophysiology laboratory, along with her chart. After the patient again expressed reluctance to undergo the procedure, the electrophysiology nurse, RN1, paged the electrophysiology attending, who returned the page promptly. He asked to speak with the patient, who again stated that she was nauseated and felt generally unwell. The attending had briefly met Jane Morrison (the correct patient) the night before but did not realize he was now speaking with a different patient. He was somewhat surprised to hear her reluctance to undergo the procedure because she had not expressed this concern the night before. After speaking with Ms. Morris, he instructed RN1 to administer intravenous prochlorperazine for nausea and stated that the patient had agreed to proceed. 6:45 to 7:00 a.m. RN1 reviewed the cart accompanying the patient and noticed no consent form, even though the daily schedule stated that consent had been obtained. She paged the electrophysiology fellow scheduled to do the procedure.

7:00 to 7:15 a.m. Upon arrival, the fellow reviewed the chart and was surprised at its relative lack of pertinent information. However, the fellow then discussed the procedure with the patient and had her sign the consent for "EP Study with possible ICD and possible PM placement" (EP=electrophysiology; ICD=implantable cardiac defibrillator; PM=pacemaker). A per diem nurse in the electrophysiology laboratory, RN3, witnessed the consent. Prochlorperazine was given after Ms. Morris signed the consent form. 7:10 a.m. The electrophysiology charge nurse arrived and was told by RN1 that a patient scheduled for an early start had arrived. No patient name was used in this conversation. The charge nurse checked the electrophysiology schedule and then left to attend to other duties. 7:15 to 7:30 a.m. RN3 placed the patient on the table, attached monitors, and spoke to the patient about her procedure. Ms. Morris stated that she had "fainted," which seemed to RN3 to be a reasonable indication for an electrophysiology procedure. 7:30 a.m. A resident from the neurosurgery team on his morning rounds was surprised to find Ms. Morris out of her room. After learning of the electrophysiology procedure, he came down to the electrophysiology laboratory and demanded to know "why my patient" (not using her name) was there, as he was unaware of an order for this procedure. RN1 informed the resident that the patient had been bumped twice already but was now being taken as the first case of the day. The resident left the electrophysiology laboratory assuming that his attending had ordered the study without telling him. 8:00 a.m. An additional electrophysiology nurse (RN4) and the electrophysiology attending arrived. The attending stood outside the procedure room at the computer console and could not see the patient's face because her head was draped. The fellow initiated the procedure, inserting femoral sheaths and beginning programmed simulation of the heart via an intracardiac electrophysiology catheter. 8:30 to 8:45 a.m. A nurse from the telemetry floor, RN5, telephoned the electrophysiology laboratory to find out why no one had called for Jane Morrison (the correct patient). RN3 took the call and, after consulting with RN4 about the expected completion time for the current case (Joan Morris), advised RN5 to send Ms. Morrison down at 10 a.m. 8:30 to 8:45 a.m. The electrophysiology charge nurse, making patient stickers for the morning cases, noticed that "Joan Morris" did not match any of the five names listed in the morning log. Entering the electrophysiology laboratory, she questioned the fellow about the patient names. He said, "This is our patient." Because the procedure was at a technologically demanding juncture, the charge nurse did not pursue the conversation further, assuming that Ms. Morris had been added after the advance schedule had been distributed. 9:00 to 9:15 a.m. Like the neurosurgery resident 90 minutes earlier, an interventional radiology attending went to Ms. Morris's room and was surprised to find it empty. He called the electrophysiology laboratory to ask why Ms. Morris was undergoing this procedure. The electrophysiology attending stated to the nurse that the call concerned a patient named Morris, but that Jane Morrison was on the table. The electrophysiology charge nurse corrected him, stating that, in fact Joan Morris was on the table. The electrophysiology attending asked to see the patient's chart and recognized the error.

Adapted from "Quality Grand Rounds" a series of articles designed to explore a range of quality issues and medical errors, published in The Annals of Internal Medicine. Develop a complete list of specific errors that contributed to Joan Morris getting the invasive cardiac study and categorize the list by which Rule of the TPS system best addresses that error. (Use the 5 rules listed in the slide titled "The Revised Rules of the TPS")

System Rule - Specify what the products & services the system will deliver, and to whom.

Work Activity Rule - Specify the work element content, sequence, timing, location, and outcome for each element in a pathway.

Connection Rule - Specify how people will request material, services, information from the proper supplier.

Pathway Rule - Specify who will do what tasks to supply what items (material, services, information) to whom over simple pathways.

Improvement Rule - Specify that problems be solved close to their occurrence in time, place, and process by those affected by the problem with the help of a teacher using a hypothesis testing experiment process.

For each category select a Lean Tool and discuss how you would apply it to prevent future errors. Your discussion should use specific examples.