Wrong-site/Wrong-patient errors

In a recent incident at DFCI, one staff member prepared the room for a bone marrow biopsy and a second staff member accepted and labeled the specimen.  Because the entire care team had not taken a time out for final verification, the second staff member accidentally mislabeled the specimen with the wrong patient’s information. Although the error was discovered at the lab and corrected, this illustrates the “wrong-patient” risk associated with bedside procedures.

In a related report, a series of wrong-site surgical errors at Rhode Island Hospital have received wide media coverage. In three wrong-site brain surgery events during 2007, surgical staff failed to follow the Universal Protocol.  After the third event, the hospital was fined $50,000 and ordered to institute a set of corrective measures. Click here to read a news article describing the events and resulting actions.