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

  • Complicity vs. protest: a doctor’s choice

    Patrick Hudson, MD
  • When cancer costs too much: Why financial toxicity deserves a place in clinical conversations

    Yousuf Zafar, MD
  • The hidden rewards of a primary care career

    Jerina Gani, MD, MPH
  • Why doctors regret specialty choices in their 30s

    Jeremiah J. Whittington, MD
  • 10 hard truths about practicing medicine they don’t teach in school

    Steven Goldsmith, MD
  • How I learned to love my unique name as a doctor

    Zoran Naumovski, MD
  • Most Popular

  • Past Week

    • Why doctors must fight for a just health care system

      Alankrita Olson, MD, MPH & Ashley Duhon, MD & Toby Terwilliger, MD | Policy
    • The human case for preserving the nipple after mastectomy

      Thomas Amburn, MD | Conditions
    • Nuclear verdicts and rising costs: How inflation is reshaping medical malpractice claims

      Robert E. White, Jr. & The Doctors Company | Policy
    • IMGs are the future of U.S. primary care

      Adam Brandon Bondoc, MD | Physician
    • Complicity vs. protest: a doctor’s choice

      Patrick Hudson, MD | Physician
    • Why I left the clinic to lead health care from the inside

      Vandana Maurya, MHA | Conditions
  • Past 6 Months

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why primary care needs better dermatology training

      Alex Siauw | Conditions
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • How a doctor defied a hurricane to save a life

      Dharam Persaud-Sharma, MD, PhD | Physician
    • What street medicine taught me about healing

      Alina Kang | Education
  • Recent Posts

    • Complicity vs. protest: a doctor’s choice

      Patrick Hudson, MD | Physician
    • How physician burnout and system reform are shaping the future of U.S. health care

      Irim Salik, MD | Policy
    • How nature is inspiring the future of pain medicine

      Varun Mangal | Conditions
    • Why doctors must fight for a just health care system

      Alankrita Olson, MD, MPH & Ashley Duhon, MD & Toby Terwilliger, MD | Policy
    • Affordable postpartum hemorrhage solutions every OB/GYN can use worldwide [PODCAST]

      The Podcast by KevinMD | Podcast
    • When cancer costs too much: Why financial toxicity deserves a place in clinical conversations

      Yousuf Zafar, MD | Physician

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

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why doctors must fight for a just health care system

      Alankrita Olson, MD, MPH & Ashley Duhon, MD & Toby Terwilliger, MD | Policy
    • The human case for preserving the nipple after mastectomy

      Thomas Amburn, MD | Conditions
    • Nuclear verdicts and rising costs: How inflation is reshaping medical malpractice claims

      Robert E. White, Jr. & The Doctors Company | Policy
    • IMGs are the future of U.S. primary care

      Adam Brandon Bondoc, MD | Physician
    • Complicity vs. protest: a doctor’s choice

      Patrick Hudson, MD | Physician
    • Why I left the clinic to lead health care from the inside

      Vandana Maurya, MHA | Conditions
  • Past 6 Months

    • Health equity in Inland Southern California requires urgent action

      Vishruth Nagam | Policy
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why primary care needs better dermatology training

      Alex Siauw | Conditions
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • How a doctor defied a hurricane to save a life

      Dharam Persaud-Sharma, MD, PhD | Physician
    • What street medicine taught me about healing

      Alina Kang | Education
  • Recent Posts

    • Complicity vs. protest: a doctor’s choice

      Patrick Hudson, MD | Physician
    • How physician burnout and system reform are shaping the future of U.S. health care

      Irim Salik, MD | Policy
    • How nature is inspiring the future of pain medicine

      Varun Mangal | Conditions
    • Why doctors must fight for a just health care system

      Alankrita Olson, MD, MPH & Ashley Duhon, MD & Toby Terwilliger, MD | Policy
    • Affordable postpartum hemorrhage solutions every OB/GYN can use worldwide [PODCAST]

      The Podcast by KevinMD | Podcast
    • When cancer costs too much: Why financial toxicity deserves a place in clinical conversations

      Yousuf Zafar, MD | Physician

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...