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Report sheds light on troubling prevalence of patient mix-ups in hospitals

It's every patient's nightmare: finding out that you received the wrong medication, dosage, test results, diagnosis or treatment because of a mix-up in medical records. In the 21st century, with medical technology having advanced leaps and bounds from even a few decades ago, patient mix-ups should never happen. Unfortunately, they still do - and with far more frequency than most people realize.

The ECRI Institute, a nonprofit organization dedicated to improving the quality of health care, recently released a report on the prevalence of medical mix-ups. The report looked at 7,613 mix-ups from 181 hospitals across the country.

The mix-ups concerned everything from medications to meals. For example:

  • One patient received a meal that didn't have the right dietary restrictions.
  • Another patient was given ten times the prescribed dosage of a powerful medication.
  • An infant was given breast milk from the wrong mother - and contracted Hepatitis as a result.
  • A patient who went into cardiac arrest wasn't resuscitated because doctors thought he was a different patient with do-not-resuscitate order.
  • A patient was cleared to undergo surgery based on a different patient's health history.

A closer look at what went wrong

Many mix-ups happened during patient registration, when two files became intermingled or duplicate records were accidentally created. Approximately one-third of the errors involved giving patients the wrong test results, which could impact their diagnoses. Approximately 22 percent involved mix-ups in treatments or procedures.

Most of these mistakes were caught before they caused harm. However, two errors were fatal, and all had the potential to wreak havoc on patients whose health was already fragile.

How can such mistakes happen in this day and age?

The report raises alarming concerns. Aren't electronic health records supposed to prevent mix-ups? Can't a simple step - such as verifying the patient's name and date of birth - eliminate mistakes?

As we highlighted in a previous post, electronic health records aren't foolproof. They have some of the same vulnerabilities as paper records. Information can be entered incorrectly. Files can get mixed up. Providers can accidentally look at the wrong file, especially when patients have confusingly similar names.

What's more, when reviewing electronic records, many providers have the ability to pull up multiple files at once. Toggling back and forth between different patient records can easily lead to errors.

Preventing mix-ups going forward

There are many ways to reduce the risk of these preventable - and inexcusable - errors. For example, the ECRI Institute recommends:

  • Including patient photos in electronic medical records so providers can verify at a glance whether they have the right person
  • Standardizing how patients' names appear in electronic records to avoid confusion between those with similar names
  • Expanding the use of barcodes and requiring providers to scan patient wristbands before administering medications or performing procedures
  • Ensuring that all surgical teams observe a "time-out" before starting surgeries to go over the patient's information
  • Always verifying patients' names and birth dates before administering medication or treatments

Nobody should have to endure lifelong complications - or the tragic loss of a loved one - due to medical mix-ups. Hopefully, the ECRI report and its recommendations will help make such mix-ups a thing of the past.

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