4 Medics Realized Hours Into Brain Surgery That They Were Operating On The Wrong Patient

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When you arrive at a hospital, you put your trust in the doctors, nurses, and staff there to provide you with the care and attention you need. Whether you’re going in for a routine procedure or you’re in need of emergency care, your life is in their hands. But as we know, doctors aren’t perfect and if there’s a mix up no matter how big or small, it can be costly.

Patient Mix Up Leads To Unnecessary Brain Surgery

patient mix up

Recently, four Kenyan medical staff from Kenyatta National Hospital were suspended, following the mix up of two patients who were brought in for treatment. One was scheduled for surgery to remove a clot from the brain, while the other needed a noninvasive procedure to reduce some swelling. Somehow, their identification tags were switched.

Doctors didn’t notice the problem until they were hours into the surgery and found no clot. Despite the mix up, the head of the hospital said that the patient is fine and in recovery [1]. Those who have been suspended are the attending neurosurgeon, ward nurse, theatre receiving nurse and anesthetist.

While Kenya’s medical board has announced that this is the first mix up of its kind for the Nairobi hospital, it isn’t the first time that Kenyatta National Hospital has been embroiled in conflict. Just six weeks ago, Kenya’s health minister opened an investigation into claims of sexual assault on new mothers at the facility [1].

Unfortunately, the issue with mixed up identities isn’t unique to this hospital. It occurs more often than you might think.

Mistaken Identities

patient mix up

A mix up when it comes to patients identities can have obvious terrible consequences and the United States is not immune. In fact, hospitals and medical practices regularly mix up identities – or more accurately – fail to match the right person to the right medical record.

According to a study by the RAND Corporation [2], nationally, health providers mismatch patients and records 8% of the time. While a small percentage, the outcomes could be anything but.

One family from Stockton, CA was left confused and angry when they discovered that their recently deceased father and husband, Mike Hernandez, was wrongly misidentified as another man who was a registered organ donor. Hernandez’s bones, skin, and other organs were harvested for donations [3].

His wife of 23 years, Lisa, was unaware that her husband was an organ donor and was only informed after his passing when she was contacted by Shawn Smith, a family care specialist representing Sierra Donor Services. The call was to confirm that Mike was an organ donor, but when going over his details, Lisa realized that they were referring to a different Mike Hernandez. This whole process occurred during a 4-hour long phone call, which was recorded, and the transcript provided to The Record [3] who reported the incident.

From transcript:

“OK, we have obviously made a mistake, and he is not registered,” Smith said. “So, given the fact that he is not registered — all we’re given when someone passes is the initial name, and the birth date. See, the Michael Hernandez matched, and the birthday matched. But all of these other things are not matching. OK?”

Then, Smith asked, “So since he is not registered, would you still like to go forward with the donation process?”

Lisa, believing her husband’s body had already begun to be harvested, gave her consent. Smith tried to allay any of her worries by telling her that Mike would still look the same way he always did.

“Everything is replaced,” Smith told Hernandez. “He will look as he looked as if he were sleeping.”

But when it came time for the funeral, Mike did not look the same as he had.

“My kids are traumatized. He did not look the same,” Lisa said. “He came back so skinny, I had to put extra clothes on him. He’s a 260-pound man. I did not realize they took all his bones from his legs and arms. I was in shock when he came back how small he was.

When it comes to your medical records and your medical history, accuracy is the most important thing. Dr. Hardeep Singh, a patient safety researcher at the Michael E. DeBakey VA Medical Center and the Baylor College of Medicine suggests taking a proactive approach to your medical records [4]. With records becoming digitized, accessing them is easier than ever and should be done actively to ensure that the information on there is accurate.

Never be afraid to ask your doctors questions and keep them vigilant. Your health is what matters, and if five extra minutes is all it would take to make sure you’re safe, take that five minutes.


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