How to Avoid Wrong-Patient Errors

There is little standardization across these systems, even on such fundamental issues as displaying patient data. While he realizes it is impossible to standardize everything, he also said there are certain high-risk processes that we have to get right with technology. One of these is patient identification. “Technology could be useful in this area but also must be used correctly,” said Dr. Singh, who was one of the authors of the ECRI report. “It has certainly made the system more transparent, and we can measure things more easily. It is easier to see when problems develop because it is documented in an EMR instead of a paper record that no one could ever find.”

The complexity of medicine makes WPEs possible. Multiple diagnostic tests, more patients, and more providers are involved in patient care, all of which increase the chance of error. Physicians are getting more information to diagnose patients than just a history and physical and basic blood work. Additionally, as the patient population ages, medical complexity and the opportunity for errors increase even more. “Between increasing time pressures, increasing patient volumes, and increasing complexity of the patients we are treating, there are certainly ample opportunities for error,” said Dr. Brenner. “This is not only in patient identification issues, but all other aspects of care.”

It appears that there is no one area of the process that can resolve all problems. Dr. Shah’s work found the domains with the most reported errors were technical (27.9%), administrative (12.2%,), diagnostic testing (10.8%), and surgical planning (9.9%). Technical and surgical planning had the highest levels of major morbidity at 71% and 45.5%, respectively.

All the experts agreed that there is no such thing as a small error. Left unaddressed, near misses may not miss the next time, and many little problems combine to become bigger ones. “There is a classic model that relates problems to Swiss cheese,” said Dr. Shah. “For an error to turn from a near miss to affecting a patient, it has to slip through various holes in the cheese. All these holes have to line up, but in healthcare there are, on average, eight slices of cheese.” This would mean that there are also eight chances to prevent an error. Otolaryngologists should know that there will be problems in their practice and, with this knowledge in mind, find ways to “block and tackle” at multiple points.

“Practices don’t realize that they can lean on the performance and quality improvement departments of the hospitals they have affiliations with. These departments can help with materials, literature searches, and plan-do-study-act cycles.” —Rahul K. Shah, MD, MBA

Reporting

Prevention is largely about reporting: If you see something, say something. Leadership buy-in may be the single most important part of addressing WPEs.