Author: Leslie W. Hall, M.D.
Title: Associate Professor of Clinical Internal Medicine
Institution: University of Missouri – Columbia
Coauthors: Kathryn J. Nelson, MHA; Director of Quality and Patient Safety; SSM St. Mary’s Health Care
Online or Web-based Modules
Examine human factors and basic safety design principles as well as
commonly used unsafe practices as they relate to an adverse event in
health care. Describe the benefits and limitations of information
systems in the improvement of health care quality. Discuss effective
strategies to improve reliability of patient identification in delivery
of health care.
Value the balance between professional autonomy and standardization
or reliability. Appreciate the cognitive and physical limits of human
performance. Recognize the value of engaging in root cause analysis
rather than blaming when error or near misses occur. Value relationship
between national patients safety campaigns and implementation in local
Use appropriate strategies to reduce reliance on memory. Demonstrate
an effective use of strategies to reduce risk of harm to others.
Participate appropriately in analyzing errors and designing systems
The attached case describes an adverse event in which the wrong
patient with a similar sounding name was contacted and asked to come to
the hospital for a procedure. Although the patient did not suffer any
permanent harm from this event, the patient did experience inconvenience
and minor discomfort, and the involved health care workers and system
suffered significant embarrassment. In reviewing this case, nursing
students are challenged to look beyond blaming one or more health care
workers for this mistake, and instead identify system issues (latent
factors) that led to the environment where such an event could occur.
They are then challenged to identify possible system interventions that
might lead to safer systems of care in the future.
We have utilized this primarily in small group settings (some
single-specialty, some interprofessional), usually in the format of a
simulated root cause analysis. However, this case could also be utilized
for computer-based training.
Learner evaluations of sessions in which this teaching case has been
utilized have indicated that the case was felt to be helpful in learning
important patient safety principles.