Surgery Performed on the Wrong Patient

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Surgery Performed on the Wrong Patient

Cause Mapping Example:

A "never event" that should come as no surprise considering its profound implications on patient safety is performing a procedure on the wrong patient. Ordinarily there are many checks to ensure that a patient's identity matches that on the procedure order.

However, sometimes a combination of oversights can result in these checks being ineffective. This is especially true when there are patients of similar names, as happened in this particular case.

A patient (patient 1) was scheduled for a procedure in the EP lab. The EP lab called up to Patient 1's floor, and were directed (incorrectly) to another floor by a person on the telephone. Although Patient 1 was on that floor, another patient with a similar name (patient 2) had been moved to another floor. The EP lab then directed Patient 2's nurse to bring Patient 2 to the lab. The nurse brought Patient 2 to the lab, over her objections, despite the lack of information in Patient 2's chart, or a signed consent form.

The various staff members at the EP lab did not verify the identity of the patient, either. However, they did notice the lack of consent form, and convinced Patient 2 to sign a consent form, for a procedure she did not need, was not scheduled for, and had opposed throughout the process.

Although the procedure was stopped partway through, when the true identity was realized, and there was no lasting injury to Patient 2, any procedure performed on the wrong patient has huge risk for patient safety.

On the downloadable PDF page, a simplified version of the process for taking patients to procedures is shown. The individual causes of the incident are identified in the Cause Map, and, where applicable, the process map. This example shows how a process map can be used to identify the various causes that led to an event.

A thorough root cause analysis built as a Cause Map can capture all of the causes in a simple, intuitive format that fits on one page. Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.

Click on "Download PDF" above to download a PDF showing the Cause Map and Process Map.

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