Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Identifying patients by more than their names

Skeptical Scalpel, MD
Physician
December 1, 2016
Share
Tweet
Share

The wrong body was cremated by the county coroner’s office in Los Angeles. Jorge Hernandez died of an overdose, and the body of another Jorge Hernandez, an indigent patient, scheduled for cremation, was also present in the morgue.

The distraught family of overdose victim Jorge Hernandez had planned a funeral with a viewing and were shocked when they were told his body had been cremated by mistake because a morgue attendant failed to verify the coroner’s case number.

According to the Los Angeles Times, “the coroner’s office has a strict policy requiring staffers to check the name and the coroner’s case number to make sure there are no misidentifications. A spokesman for the corner ‘said this system has generally worked.’”

That’s reassuring.

The coroner’s office is short-staffed and underfunded, but it’s hard to believe they’re so busy that no one had time to check a number which might take all of 10 seconds.

The family has retained a lawyer.

Another case of mistaken identity recently occurred in Massachusetts where the wrong patient had a kidney removed.

Although details are vague, the mixup apparently began before the patient was admitted to the hospital. Another patient with the same name had a CT scan showing a tumor in the left kidney.

The wrong patient was admitted and underwent a left nephrectomy. That patient’s medical record contained no CT scan report showing a tumor. Whether the actual CT scan images were viewed in the operating room on a digital radiology system is unknown. No tumor was found on pathologic examination.

Since the error originated outside of the hospital, it blamed the surgeon and said its personnel had followed proper procedures.

However shortly after the incident, the State Department of Public Health conducted a five-day investigation and found numerous deficiencies in the hospital’s protocols and response to its internal investigation.

The Boston Globe said CMS has threatened to end the hospital’s participation in Medicare if all the problems are not corrected by December 12.

This wrong site surgery is a little different than the more common ones that involve calling for the wrong patient or operating on the right patient but doing the wrong procedure. That a doctor’s office would have two patients with the same name both of whom must have had abdominal CT scans at about the same time is quite a coincidence, but it happened. It is not clear whether the surgeon mixed up the two patients or was referred the wrong patient.

We don’t know the size of the tumor, but since the resected kidney was normal, was it thoroughly examined visually and by palpation before it was removed from the patient?

ADVERTISEMENT

In addition to using a minimum of two patient identifiers, I was always taught the first thing you should do when you look at an x-ray or a report is to make sure it refers to the correct patient.

I am sorry for the patient who lost a normal kidney and the surgeon who will be haunted by this forever.

This is a cautionary tale for any medical professional especially those who scoff at using two patient identifiers. I hope more information becomes available so we all can learn from this mishap.

“Skeptical Scalpel” is a surgeon who blogs at his self-titled site, Skeptical Scalpel.  This article originally appeared in Physician’s Weekly.

Image credit: Shutterstock.com

Prev

Are nudists, nature, and hippies the cure for an uptight doctor?

December 1, 2016 Kevin 2
…
Next

When should you talk to your teenage daughter about sex?

December 2, 2016 Kevin 0
…

Tagged as: Surgery

Post navigation

< Previous Post
Are nudists, nature, and hippies the cure for an uptight doctor?
Next Post >
When should you talk to your teenage daughter about sex?

ADVERTISEMENT

More by Skeptical Scalpel, MD

  • The hospital CEO who made a surgical incision. What happened?

    Skeptical Scalpel, MD
  • Medical error is not the third leading cause of death

    Skeptical Scalpel, MD
  • Should speed-eating contests be banned?

    Skeptical Scalpel, MD

Related Posts

  • Are patients using social media to attack physicians?

    David R. Stukus, MD
  • You are abandoning your patients if you are not active on social media

    Pat Rich
  • Physician Suicide Awareness Day: Where are the patients? 

    Jennifer M. Sweeney
  • Is physician shadowing immoral?

    David Penner
  • A love letter to patients

    Marcie Costello
  • Patients are not passengers

    Christopher Noll, RN, MSN

More in Physician

  • Why more doctors are choosing direct care over traditional health care

    Grace Torres-Hodges, DPM, MBA
  • How to handle chronically late patients in your medical practice

    Neil Baum, MD
  • How early meetings and after-hours events penalize physician-mothers

    Samira Jeimy, MD, PhD and Menaka Pai, MD
  • Why medicine must evolve to support modern physicians

    Ryan Nadelson, MD
  • Why listening to parents’ intuition can save lives in pediatric care

    Tokunbo Akande, MD, MPH
  • Finding balance and meaning in medical practice: a holistic approach to professional fulfillment

    Dr. Saad S. Alshohaib
  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • America’s ER crisis: Why the system is collapsing from within

      Kristen Cline, BSN, RN | Conditions
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Beyond burnout: Understanding the triangle of exhaustion [PODCAST]

      The Podcast by KevinMD | Podcast
    • Facing terminal cancer as a doctor and mother

      Kelly Curtin-Hallinan, DO | Conditions
    • Online eye exams spark legal battle over health care access

      Joshua Windham, JD and Daryl James | Policy
    • FDA delays could end vital treatment for rare disease patients

      G. van Londen, MD | Meds
    • Pharmacists are key to expanding Medicaid access to digital therapeutics

      Amanda Matter | Meds
    • Why ADHD in women requires a new approach [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 4 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • America’s ER crisis: Why the system is collapsing from within

      Kristen Cline, BSN, RN | Conditions
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Beyond burnout: Understanding the triangle of exhaustion [PODCAST]

      The Podcast by KevinMD | Podcast
    • Facing terminal cancer as a doctor and mother

      Kelly Curtin-Hallinan, DO | Conditions
    • Online eye exams spark legal battle over health care access

      Joshua Windham, JD and Daryl James | Policy
    • FDA delays could end vital treatment for rare disease patients

      G. van Londen, MD | Meds
    • Pharmacists are key to expanding Medicaid access to digital therapeutics

      Amanda Matter | Meds
    • Why ADHD in women requires a new approach [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Identifying patients by more than their names
4 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...