Misidentification of a Patient

Case Synopsis

A 12-year-old boy was brought to the operating room for a liver transplant late one Sunday evening. Frequent blood draws were done throughout the case, and the tests were run on a point-of-care machine in the operating room. The machine allowed for both manual and barcode input of the patient’s medical record number. However, the manual input was disabled several years ago in all of the operating rooms when several providers found that the touch screen keypads were difficult to use and resulted in several instances of laboratory tests attributed to the wrong patient. The anesthesiologist used the barcode on a wristband removed from the patient because his arms were going to be tucked and thus inaccessible. Though used for several laboratory tests, this barcode proved to be difficult to scan, and the circulator was asked for the facesheet, which also contained the barcode. After several sets of tests, it was noted that the facesheet was incorrect, and further investigation revealed that it had been left at the circulating nurse’s workplace from a prior liver transplant 2 days before. The anesthesia team traced that patient to the pediatric intensive care unit (PICU) and notified the team of the error. The team in the PICU had noted laboratory tests appearing in the medical record and was beginning an investigation of a drop in hemoglobin along with several other critical values, when an astute nurse noted that she had not sent any laboratory tests in the last several hours. After several lengthy calls to technology support for the hospital, the errant test results were finally assigned to the correct patient.