against the wristband, consent form and other documents. Only then should the surgical site be marked.
Barcode technology is another patient identifier. The wristband, patient specimens, medications and blood all have the same barcode and they must match with every therapeutic or diagnostic procedure performed.
Patients must be certain that they undergo proper identification when approached by hospital or clinic personnel.
Wrong site procedures include wrong person, wrong site, wrong organ, and wrong implant. This error is preventable, but does occur. Eighty-eight cases occurred in 2005. Preventive protocols are in place:
•During the pre-procedure stage, verbal questioning, by wristband and by consent form must identify patients. The procedure, site, and any prosthesis or implant must also be identified
•Whoever performs the procedure must mark the preoperative site while the patient is awake and aware
•The entire operating room staff will take a “time out:” a time period where no clinical activity is taking place and all staff can concentrate on identification verification, positioning, procedure site and any prosthesis or implant that is to be used
Performance of correct procedure at correct body site
A patient must sign a consent form when undergoing surgery or an invasive test of any type. The patient reads the consent form. Patients are entitled to understand the nature of the procedure, the benefits that are supposed to accrue, other possible alternatives to the procedure and the risks of the procedure.
The surgical site is marked as described; wrong site or side surgery is a tragedy that cannot be undone.
Communication failures during patient handovers
A number of health-care practitioners and specialists in many settings including emergency rooms, acute care hospitals, outpatient clinics, intensive care, and rehabilitation units treat patients. Patients will meet different professionals on three different shifts. Medical information must remain unchanged when leaving one unit to transfer to another unit. It is unfortunate that at this critical transfer time, breakdowns in the transfer of information do occur and may lead to serious consequences. This is the time for the patient to be alert—assuming one can.
This is another one of the main causes of medical errors. Here is an illustrative example:
A forty-nine year old woman had a sudden episode of unconsciousness manifested by a seizure. Paramedics transported her to the closest hospital emergency department. A CT scan of the brain revealed a right frontal cerebral bleed. The cause of the bleeding could not be determined from the scan. The medicated patient was unresponsive, restless and agitated, and regained consciousness within ten hours. There was no apparent neurological residual, and on subsequent clinical and MRI follow up over a year, the blood resolved leaving no trace of the underlying pathology. She was on anti-seizure medication for a time, and remained symptom free for one and a half years. Then she had another similar but much shorter episode, regaining consciousness within a half-hour. Extensive brain studies demonstrated normal cerebral arteries and ruled out arteriovenous malformation, cerebral aneurysm, arteriovenous fistula, dural sinus fistula, brain tumor and other diagnostic possibilities. This left some rarer diagnostic possibilities.
I was not the patient’s doctor, but, at the patient’s request, I spoke with the neuroradiologist who had interpreted her MRI films taken during hospitalization. Since the usual MRI did not reveal the source of the bleeding, he recommended an MRI of a type that I had not heard about. He thought that an “MRI with and without infusion, T2 star gradient with echo” might be able to pick up the lesion where the regular, routine MRI’s could not. I had him repeat the exact test, and I wrote it down and he confirmed that what I wrote was accurate. The neuroradiologist assured me that this special test was the best chance of diagnosing what he now suspected after ruling out so many other possibilities.
I then gave a copy of the test to the patient who by this time was being discharged and learned to her dismay that the excellent neurologist assigned to her case when she was admitted was not a participating doctor for her HMO, nor was the hospital she was admitted to as an emergency a part of the HMO network. She had to start over. I told the patient to take charge of and direct her own healthcare. She was now responsible for acquiring a new medical team, and these physicians had to learn about her and take over all future care; and the quicker the better because of a probable delay in the transfer of her records to any new doctor. The HMO directed that she go to another hospital for the test further disturbing the continuity of her care. She was in the middle of a fabricated healthcare maze prone to miscalculations and misadventures because her course had changed and many human beings were involved. As we embark on the new and massive changes in healthcare to come, the situation may worsen. That is why all patients or their advocates must be in charge.
“But I’ll just have the new doctor order that test you wrote out for me. Why should I worry?” she asked.
“You should worry,” I said, “because the neuroradiologist gave me the information about this test, that in all my experience I had never heard about, which I now pass on to you, and you will pass it on to the new doctor, and he will tell his secretary, who will call the hospital and speak to another secretary, who will then speak with a radiological technologist to put you on the schedule for the recommended and unusual test, which by now has passed through multiple hands. In addition, by the time the order has passed through this maze, God knows what it will look like when you appear for the test. Trust me—these foul-ups do occur.”
She took my advice and in attempting to confirm that the new hospital could perform the test, she learned that it could not. What they had done already was place her on the schedule to do the usual MRI. Unfortunately, the usual MRI did not identify the cause of her bleeding. She phoned the HMO to tell them that they had approved the test at a hospital that could not perform it and the hospital had scheduled the wrong test anyhow. This resulted in multiple and lengthy phone hassles until she assured them that she was attempting to prevent them from making a medical error. They advised her of another hospital where the proper test could be performed.
The patient, now the wiser in the ways of potential medical error production, went so far as to call the technologist at the second hospital that would be doing the test. Reading from the paper I gave her, she said, “This is the precise test that the doctor ordered,” “Yes, we will do that,” answered the technologist, J. “I will be performing it myself,” he said.
I told her to be sure when she went for the test, even though she had spoken to the person who would perform the test, that she confirm that the exact test that had been ordered was to be done. She assured me that it was now foolproof, because she had personally spoken with J. who would perform the test. I repeated what I told her.
Well you guessed it—when she arrived for the test and filled out forms stating the test ordered, J. was not there, but another technologist had replaced him. The patient was wise enough to understand this woman was not J., so she asked her where J. was. “Oh, he couldn’t be here today,” she answered. “What test are you going to perform?” the patient asked. The woman technologist answered, “Just a regular MRI.”
The patient controlled herself and said, “No that’s not correct. Here is the exact test that was ordered,” and she handed her the instructions.
“Oh,” said the technician, “that’s a test we don’t do very often, but if that’s what you want we can do it if we get a doctor’s order for it.” “It’s not what I want,” the patient responded, “It’s what the doctor ordered and what J. said he would do.” They did the test after taking more time to confirm the doctor’s order
