Thousands of incidents of wrong patient and wrong side/site surgeries occur every year in the United States. In general, patient identification errors (PIE) pose the most dramatic consequences that may even lead to patient death. While some PIE lead to taking the wrong medication, others lead to reporting the wrong laboratory or radiological reports to the wrong patient. Interestingly, these drastic scenarios can simply be prevented by following the patient identification protocols which usually rely on using two identifiers or more according to the policy in use. This paper uses the root cause analysis to identify possible actual causes that contribute to the recurrence of PIEs with special highlight to the emergency and surgery rooms. It also recommends a risk management plan designed to prevent recurrence of these tragic events while placing emphasis on quality initiatives.
While operating on the wrong patient or wrong site/side is mainly a human error, there are contributing factors that lie behind its occurrence. It is estimated that 1500-2500 wrong patient/site/side surgeries are performed annually in the United States (Chan et al., 2010). That led JCAHO to list the problem among its priorities to eliminate on 2003 (JCAHO, 2002) and among the World Health Organization top 10 goals in 2009 (Chan et al., 2010). Moreover, JCAHO strongly recommended the use of root cause analysis by all management teams to analyze, report, and prevent risk taking (Dattilo & Constantino, 2006). By applying root cause analysis, operations performed on patients admitted through the emergency room are subject to many identified risks that can take place at three different locations: the emergency room, admission wards, and the surgery theatre (Chan et al., 2010).
According to Chan et al. (2010), in the emergency room, misidentification may happen due to lack of identification policy, language barrier, miscommunication, tiredness, work over-load due to insufficient staffing, and/or human error. After admission, misidentification can happen due to miscommunication, transcription error, ineffective or no adherence to the identification policy, language barrier, tiredness and human errors. Lastly, in the surgery theatre, misidentification may happen due to the same factors formerly mention plus failure to mark site/side of surgery, failure to properly perform time-out, and multiple surgical teams (Chan et al., 2010). To analyze the risk for these errors, few factors will be analyzed including human factors (staffing, scheduling, supervision, and qualification), equipment and technology (scanners, computers, and software), Communication (between staff and patients, between staff, between staff and physician, between physician and patient, and between units), environmental factors (physical, safety, security, and preparedness), and procedures and policies (planning, staff education, patient education, protocols, patient identification, and patient...