When a patient goes to the hospital for surgery, they expect the surgeons to check and double-check that they are operating on the right patient. Doctors should verify the patient’s identity, medical procedure, and make sure they have they know whether the surgery is to take place on the right or left side of the body. However, doctors have operated on the wrong patient because they shared the same name as another patient in the hospital.
One same-name patient mix-up was used as a case study in the Annals of Internal Medicine. Doctors Mark R. Chassin and Elise C. Belcher looked at the case, to determine what happened, and how similar events could be avoided in the future. The case uses the pseudonym of Joan Morris for the 67-year-old woman who suffered from an unnecessary surgery.
Joan Morris was admitted to a teaching hospital for a cerebral angiography. A cerebral angiography is a diagnostic test to evaluate blood vessel blockages in the patient’s head and neck. This test can be used to diagnose an aneurysm, blood clots, vasculitis, tumors, or arteriosclerosis. After the angiography, Morris was operated on for an invasive cardiac electrophysiology study meant for another patient.
Morris is described as a native English speaker and high school graduate with a daughter who was a physician. She went to the hospital after falling and hitting her head. An MRI showed two large cerebral aneurysms. She was admitted to the hospital in order to get the cerebral angiography. After the test, doctors planned surgical therapy for one of the aneurysms. She was transferred to the oncology floor to be discharged the following day.
The next day, instead of being released, she was taken for the cardiac electrophysiology study. It was not until almost an hour into the surgery that doctors discovered Ms. Morris was the wrong patient. The ‘right’ patient was instead Jane Morrison.
On the morning of Ms. Morrison’s surgery, a nurse called to ask for “patient Morrison.” The person on the telemetry floor incorrectly said the patient was moved to oncology. When the nurse called oncology to ask for patient Morrison, the nurse was told the patient would be brought to the electrophysiology lab. Ms. Morris’ nurse brought the patient to the lab, despite there being no mention of any such procedure.
When Ms. Morris was awoken, the nurse said she had an appointment. Morris responded, “No, I don’t. I told my children and I told the doctors I did not want to do anything else right then.” The nurse ignored her statement and took her up to the lab. The attending physician did not notice that the patient was a different person than Ms. Morrison, who he had met the night before. The patient’s chart had no consent form and little pertinent information for such a procedure. However, the electrophysiology fellow had Morris sign the consent form for the unnecessary procedure.
When a neurosurgery resident found that Ms. Morris had been taken for a procedure, he came to the electrophysiology lab and demanded to know why his patient was there. The nurse said the patient was undergoing a procedure, and the resident left, assuming the attending had ordered the procedure without informing him. At least two other individuals had asked why Morrison was not in the lab, and why Morris had been moved. Finally, after an interventional radiology attending doctor called to ask why Ms. Morris was undergoing the procedure did doctors realize their error.
According to researchers of the case study, there is little information about these adverse events. Reporting to the Joint Commission on Accreditation of Health Care Organizations keeps a database of wrong-patient errors; however, reporting is voluntary. Even mandatory state-level databases may underestimate the occurrence of wrong-patient surgical errors.
If you or a loved one has been injured or emotionally harmed as the result of a negligent doctor, the Gilman & Bedigian team of experienced attorneys is fully equipped to handle your claim. Our staff includes a physician and attorneys with decades of malpractice litigation experience. We focus on getting you compensation for your injuries so you can focus on getting better and moving forward with your life.
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