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http://www.nytimes.com/2002/06/18/health/policy/18ERRO.html

Oops, Wrong Patient: Journal Takes on Medical Mistakes

By DENISE GRADY

he patient had been on the operating table for an hour. Doctors had made an incision in her groin, punctured an artery, threaded in a tube and snaked it up into her heart. Now they were stimulating her heart electrically, to test for abnormal rhythms.

The phone rang: it was a doctor from another department. What, he asked, were they doing with his patient? There was nothing wrong with her heart.

The cardiologist working on the woman checked her chart, and saw that he was making an awful mistake. He was performing an invasive procedure — with risks of bleeding, infection, heart attack and stroke — on the wrong patient.

The case, described in an article in the June 4 Annals of Internal Medicine, took place several years ago at a teaching hospital. Doctors and administrators there, in exchange for anonymity, agreed to discuss the case and share the records with outside experts, who also interviewed the patient. The resulting article, by the experts, is the first of eight detailed reports on medical errors that will be published in the journal over the next year or so. The article, "The Wrong Patient," is available at www.annals.org.

Creating a series of articles on mistakes was the idea of Dr. Robert M. Wachter, associate chairman of the department of medicine at the University of California at San Francisco, and a colleague, Dr. Kaveh G. Shojania. They asked doctors around the country to reveal their mistakes, with the promise that no names would be published. Cases were then analyzed and written up by experts who did not work at the hospitals involved. The goal, Dr. Wachter said, is to help prevent mistakes by showing how they occur.

The series was inspired in part by a 1999 report by the Institute of Medicine, which found that mistakes in hospitals killed 44,000 to 98,000 patients a year. Departments within hospitals try to analyze their own errors, at regular "morbidity and mortality" conferences, but those sessions are private and are not written up in medical journals. Generally, the conferences are not discussed with patients. In an editorial about the new series, Dr. Wachter and his colleagues wrote that the medical profession — "for reasons that include liability issues and a medical culture that has discouraged open discussion of mistakes" — was not harnessing the full power of errors to teach.

"I can't imagine the hospital you could go to where someone with a straight face could tell you, `This can't happen at our hospital,' " Dr. Wachter said. "It shouldn't. I don't want to scare people. It doesn't happen very often. But it can."

Reports of mistakes — amputating the wrong leg, operating on the wrong side of someone's brain, killing a cancer patient with an overdose of chemotherapy — provoke public fear and outrage. People are often tempted to blame someone for being incompetent, careless or lazy. But the cause is rarely so clear-cut, according to the 1999 report and researchers who have studied medical errors.

Far more often, a big mistake results from a series of small ones, made in hospitals that lack systems to prevent human error or compensate for it. Singling someone out for punishment does nothing to fix underlying flaws in the system that set the stage for mistakes — flaws like different medicines having similar names or labels, or hospitals with such poor record keeping systems that doctors lack vital information on patients they are treating.

There is little data on cases like the first one in the series, in which an invasive procedure was done on the wrong patient.

"There are more newspaper articles about it than there are journal articles," said Dr. Mark R. Chassin, an author of the article and the senior vice president for clinical quality at Mount Sinai Hospital in Manhattan. Dr. Chassin was also an author of the 1999 Institute of Medicine report. He and his co-author on the new article, Dr. Elise C. Becher, also from Mount Sinai, found that a national database of voluntary reports showed 17 such cases in the last seven years. But New York alone, where reporting is mandatory, had 27 cases just from April 1998 through December 2001. And even with mandatory reporting, Dr. Chassin said, many cases are probably never revealed.

The tale of the wrong patient in the first article, Dr. Wachter said, "is one of these cases where light bulbs go off in people's heads and they say, `Wow, I now understand how something like this can happen.' It truly is not bad people doing bad things. It's little things coming together."

The story began with two patients who had similar names; the journal used the pseudonyms Mrs. Morris and Mrs. Morrison. Mrs. Morris, 67, had a weak and bulging blood vessel, an aneurysm, in her skull. Mrs. Morrison, 77, needed a procedure called an electrophysiology study to check out her heart. They started out on the same hospital floor, but Mrs. Morris was later moved.

Early one morning, a nurse called Mrs. Morrison's floor to say it was time for her procedure. Mistakenly — mishearing the name, perhaps — the person who answered said Mrs. Morrison had been moved to another floor. The nurse then called Mrs. Morris's floor, where another person made a similar mistake, saying yes, Mrs. Morrison was there.

At 6:30 a.m., a nurse woke Mrs. Morris — the wrong patient — and told her it was time to go. The nurse went ahead even though there was no written order for the procedure on Mrs. Morris's chart, and even though the other nurses caring for her had never mentioned it.

Mrs. Morris protested, saying she had not been told about this procedure and did not want it. The nurse, who was near the end of her shift, insisted.

"She just zoomed in and took me on out of there," Mrs. Morris later told interviewers.

In the lab, Mrs. Morris protested again. A nurse called the senior doctor, the attending physician, who then spoke to Mrs. Morris on the telephone, assuming mistakenly that she was Mrs. Morrison, whom he had met the night before. After they spoke, the doctor told the nurse that the patient was willing to proceed. No one realized that the patient was not Mrs. Morrison — who was still in her room, waiting for her heart test.

But the nurse in the electrophysiology lab noticed that there was no consent form in the chart, even though the department's records said consent had been obtained. The nurse called a second doctor. He was puzzled by the "relative lack of pertinent information" in the patient's chart, but he talked to Mrs. Morris, and she signed the consent form.

Meanwhile, a resident on Mrs. Morris's floor was surprised to find that she had been taken to the electrophysiology lab. He went there, and was told by a nurse that a heart test had been scheduled for her. He left, assuming that a senior doctor had ordered the test without telling him.

The electrophysiology attending physician arrived — the one who had just spoken to Mrs. Morris on the phone and met Mrs. Morrison the night before. But Mrs. Morris's face was already hidden by surgical drapes, and he did not pause to greet her. The procedure began.

Soon after, an electrophysiology charge nurse noticed that no patient named Morris was on the schedule. She questioned the second doctor, who said, "This is our patient." The nurse backed off.

Back on Mrs. Morris's floor, a senior doctor who had begun looking for her called electrophysiology to find out why she had been taken there. Only then was the mix-up discovered, and the procedure aborted.

Mrs. Morris recovered. She did not sue. She was even magnanimous, noting that at least the test had shown that her heart was fine.

How could it have happened?

Dr. Chassin and Dr. Becher identified 17 separate errors. Doctors and nurses failed repeatedly to check the patient's identity. When she objected to the procedure, no one took her seriously. Nurses and doctors disregarded the absence of a written order or signed consent form, which should have been red flags. Though Mrs. Morris finally did sign the form, she could not have given truly "informed" consent. Indeed, she later told an interviewer that she had been awakened from a deep sleep that morning, and did not even remember having signed the consent form.

Neither language barriers nor accents caused the mix-up, Dr. Wachter said.

Whether long hours and fatigue played a role is not known, Dr. Chassin and Dr. Becher said, though the nurse who "zoomed in" on Mrs. Morris was finishing her shift and may have been in a hurry to go home. They also note that with shorter hospital stays and increasing subspecialization in medicine, patients are more likely today than in the past to be treated by doctors who have never seen them before.

Underlying the cascade of errors, Dr. Chassin and Dr. Becher said, may have been "a culture of low expectations," in which hospital staff had gotten used to poor communication, a lack of teamwork, sloppy record keeping and a patchwork of computer systems that did not allow one department to transfer a patient's records to another department. Mrs. Morris observed that her name on her hospital bracelet was printed in tiny letters and buried in a mass of other data; she wondered if someone would have noticed her name if the type had been bigger.

The hospital quickly set up systems to make sure that workers checked the identity of their patients and did not perform procedures unless written orders for them were recorded in the patients' charts.

"These are good first steps," Dr. Chassin said. "But we were not thrilled with the thoroughness of the reactions at the hospital. They did not seem to address the communication and teamwork failures. We urged them to pay much more attention to the informed consent failure. That was clearly a line of defense that was very porous in this case."

Dr. Chassin said some doctors elsewhere thought the case had little relevance to them. That view, he said, fails to recognize a major problem. "Crummy communication is ubiquitous in large institutions," he said. "The same teamwork and communication failures will lead to mistakes in other parts of the hospital."

Some patient safety advocates warn people that they must be vigilant in the hospital — marking the leg to be operated on and the one to be left alone, for instance, or having a family member or even a private nurse present.

On the one hand, Dr. Chassin said, that makes sense. On the other, he said: "That's absurd. Why should we have to rely on patients to protect themselves? Hospitals ought to be the safest places in the world."

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