Identifying patients by more than their names

The wrong body was cremated by the county coroner’s office in Los Angeles. Jorge Hernandez died of an overdose, and the body of another Jorge Hernandez, an indigent patient, scheduled for cremation, was also present in the morgue.

The distraught family of overdose victim Jorge Hernandez had planned a funeral with a viewing and were shocked when they were told his body had been cremated by mistake because a morgue attendant failed to verify the coroner’s case number.

According to the Los Angeles Times, “the coroner’s office has a strict policy requiring staffers to check the name and the coroner’s case number to make sure there are no misidentifications. A spokesman for the corner ‘said this system has generally worked.’”

That’s reassuring.

The coroner’s office is short-staffed and underfunded, but it’s hard to believe they’re so busy that no one had time to check a number which might take all of 10 seconds.

The family has retained a lawyer.

Another case of mistaken identity recently occurred in Massachusetts where the wrong patient had a kidney removed.

Although details are vague, the mixup apparently began before the patient was admitted to the hospital. Another patient with the same name had a CT scan showing a tumor in the left kidney.

The wrong patient was admitted and underwent a left nephrectomy. That patient’s medical record contained no CT scan report showing a tumor. Whether the actual CT scan images were viewed in the operating room on a digital radiology system is unknown. No tumor was found on pathologic examination.

Since the error originated outside of the hospital, it blamed the surgeon and said its personnel had followed proper procedures.

However shortly after the incident, the State Department of Public Health conducted a five-day investigation and found numerous deficiencies in the hospital’s protocols and response to its internal investigation.

The Boston Globe said CMS has threatened to end the hospital’s participation in Medicare if all the problems are not corrected by December 12.

This wrong site surgery is a little different than the more common ones that involve calling for the wrong patient or operating on the right patient but doing the wrong procedure. That a doctor’s office would have two patients with the same name both of whom must have had abdominal CT scans at about the same time is quite a coincidence, but it happened. It is not clear whether the surgeon mixed up the two patients or was referred the wrong patient.

We don’t know the size of the tumor, but since the resected kidney was normal, was it thoroughly examined visually and by palpation before it was removed from the patient?

In addition to using a minimum of two patient identifiers, I was always taught the first thing you should do when you look at an x-ray or a report is to make sure it refers to the correct patient.

I am sorry for the patient who lost a normal kidney and the surgeon who will be haunted by this forever.

This is a cautionary tale for any medical professional especially those who scoff at using two patient identifiers. I hope more information becomes available so we all can learn from this mishap.

“Skeptical Scalpel” is a surgeon who blogs at his self-titled site, Skeptical Scalpel.  This article originally appeared in Physician’s Weekly.

Image credit: Shutterstock.com

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