Posted on behalf of Marianne Soucy, Director, Client Solutions Group
An article picked up by my local news outlet a week or so ago led me to literally gasp out loud as I considered the potential implications: Due to similar names and demographics, a transplant team had given a much needed organ to the WRONG PATIENT.
Stopping to think about that for a moment, putting myself in the shoes of how one might even begin to explain that kind of mistake to a patient’s family, I literally just had no words.
While this kind of mistake is headline making both in terms of its gravity and rarity, small mistakes like this do happen every day. Recently a friend who shares a name with his father was telling me a story about his pharmacy refusing to release a newly prescribed medication to him because of other interactions with meds “he” was on, according to their computerized history. These drugs would have interacted very badly.
Only he isn’t on them, his father who shares the same first and last name, is. Rectifying the mix up to get the medication he needed in place caused quite a hassle. He understood the pharmacist’s concern for his safety, and is used to it as it happens all the time.
Small annoyances or large mistakes like this can happen without sufficient protocols in place to ensure that patient’s medical history is stored under a unique Medical Record Number. The duplication and inaccuracy rate in MRN’s across the US hospital system is estimated at 10% on average. In large trauma centers with a high Doe patient rate, or in hospitals catering to pediatric needs, that number is estimated to be even higher. Compounding these issues are practical concerns like hospital mergers, HCIS migrations and upgrades, and other large scale data activities that can either create or exacerbate the problem of medical record fragmentation.
In the news article I mentioned, the staff freely admitted that proper precautions were not followed and the mistake should have been caught well before it got to the clinical stage. Is your hospital providing staff with every tool you can to help combat duplicate, inaccurate, or incomplete MPI issues?
Please let us know if we can help you with some tools and analysis to see where your hospital stands! Contact us for more information.
News article referenced above: