Performing a procedure on the wrong patient is one of the rare and least defensive medical errors that happen in the medical field. Regarding the case study where my Jane Morris was mistaken for Joan Morrison, data collection and data analysis played the major role in the occurrence of the error (Chassin & Becher, 2002). This is because the genesis of the confusion started when two people with the same pseudonyms were used. Morris was a direct admission to the telemetry unit, and Morrison was a transfer. Morris was subsequently transferred from telemetry to oncology. It was due to the similarity nature of the names that one of the staffs gave an erroneous report that Morris, the wrong patient, was transferred to oncology, instead of Morrison, when electrophysiology called looking for Morrison who was supposed to undergo the procedure. The mistake in the identification of the appropriate patient due to the similarity in the pseudonyms was the primary cause of the errors caused by data collection. In data analysis, the nurses and doctors failed to pay attention to the document information which led to them performing the procedure on a wrong patient. Although the names of the patients were somehow similar, they had different health needs which were appropriately documented. Wrong data analysis led to the physicians overriding the recorded information for Ms. Morris, which ended to her being operated wrongly.
In my opinion, proper verification of patients' description would have helped in averting this error. The moment the physicians discovered that the patient's data didn't recommend her for the procedure, they would have sought to know why there was no information on the same. This would have led to verification by multiple parties from staff, nurses and doctors to ascertain if there were multiple bookings on the same name.
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Errors come as a result of various reasons. These may include, ineffective communication, lack of sovereignty any authority among physicians and assumptions. When there is a communication barrier, the errors are bound to occur since the message relayed may be understood erroneous (Carney, 2006). If proper communication were observed in this case, the unidentified staff who gave a wrong report concerning Ms. Morris would have verified the details before giving the statement. Also, the nurses would have noted the error after the talk with Ms. Morris. Secondly, some staff lacked sovereignty and authority, thus failing to question procedure and lastly, the application of assumptions without reliable data. Although the physician discovered the client had no documentation for the procedure, they assumed that there was an error in documentation and indeed Ms. Morris was the correct patient for the procedure. Practicing sovereignty and authority among physicians should be a key thing in their work. Also, effective communication and keenness in details will help alleviate such errors in service delivery.
References
Carney, B. L. (2006). Evolution of wrong site surgery prevention strategies. AORN journal, 83(5), 1115-1122.
Chassin, M. R., & Becher, E. C. (2002). The wrong patient. Annals of Internal Medicine, 136(11), 826-833.
