Introduction
I recently became aware of a case where a medical intern correctly performed a procedure but on the wrong patient. Intended for the patient in room 501, the patient in room 510 received it. Whoops! Unfortunately, medical errors due to mistaken identity are not rare.
A Perfect Storm
How did it happen? The medical error triggered an administrative inquiry, required by law in many states. As usual, when a major accident occurs (eg, a plane crash, a power outage, a ship stuck in the Suez Canal), a perfect storm of factors contributed.
First, the doctor had just begun his rotation and didn't know the patients. Second, there were more patients than usual. Third, both patients in rooms 501 and 510 were confused and didn't know their own names. (Patients are often too ill, injured, or disabled to speak up for themselves.) Fourth, due to COVID-19 visitor restrictions, no family members were present. Fifth, the nurse was overwhelmed with too many patients to notice the error. Sixth, no formal "time out" protocol was followed (see below).
Luckily, other than the inconvenience and discomfort, the patient suffered no permanent injury. The young doctor, however, continues to suffer guilt over his error.
