Mark R. Chassin, MD, MPP, MPH; Elise C. Becher, MD, MA*
*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, firstname.lastname@example.org.
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.
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.
Appendix Table 1. Individual Errors in This Case
Appendix Table 2. Changes Instituted in Response to the Root-Cause Analysis
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Chassin MR, Becher EC. The Wrong Patient. Ann Intern Med. 2002;136:826-833. doi: 10.7326/0003-4819-136-11-200206040-00012
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Published: Ann Intern Med. 2002;136(11):826-833.
Hospital Medicine, Neurology.
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