# The Right Patient



## JJR512 (Oct 15, 2007)

The other day, on the job with a commercial ambulance company, on a BLS unit we got a page to pick up a patient at a hospital ICU to transport to a local nursing home. My partner and I thought that was a bit strange, as the BLS units usually don't take someone out of the ICU, and ICU patients usually don't go to a nursing home. So we got in there and at the first nurse's station in the ICU, I say "We're here for So-and-so" (I ask for the Pt. by name). A nurse says she's in room 15 on the other side of the unit. So we walk to the other side of the unit with our stretcher, and see some people standing around the door to room 15. They appear to be family members and have a concerned look about them. A nurse comes out of the room and comes up to us and says that we might not be transporting this patient because she's taken a sudden turn for the worse, and the family doesn't want her to die in the back of an ambulance, they want her to either die at the hospital or at the hospice. The nurse then goes to check if the hospital can keep her longer. One of the family then asks us if we know how to get to the hospice, and I said I was confused because they're talking about this hospice in one town while our dispatch was to take the patient to a nursing home in another town. The family is quite adamant that the Pt. is going to this hospice, so my partner checks the discharge paperwork, sees the destination is the hospice, and then he calls our dispatcher to notify him of the change. All is well. The nurse then informs us that the Pt. is already discharged so she cannot stay. My partner and I begin preparing the Pt. for transport, and I'm not sure how it came up in the conversation but it turned out the family thought another competitor company was transporting the Pt. The family doesn't mind or care one way or the other; they just thought it was someone else coming for her. Anyway, the family leaves so they can be at the hospice when we get there, and we get the Pt. all set on the stretcher and are heading out the unit, and we stop at the nurse's station again to get the final discharge summary. It hasn't been printed yet, so while they're doing that, I start copying some info from the rest of the patient's chart onto my forms (meds, history, SSN, DOB, etc.), but I notice the name on the face sheet (some may know it as a demographics form) isn't the name of the Pt. we came there to get. I get mildly alarmed but I have found paperwork for the wrong patient mixed in with the correct patient's paperwork several times. So I check the patient's wrist band and to my dismay it matches the name on the face sheet, which is not the name we came there to get, and is not the name I asked for, which means we had the wrong patient on our stretcher! I tell the staff about this and one of the nurses at the station says "This makes us look very bad". They comment on the fact that we didn't check the wrist band at first and I remind them that I asked for the Pt. by name and they told me where she was. Technically they are correct; I should have checked the wrist band. But I usually don't when the nurse tells me where the Pt. is! So it all finally made sense: Why we were expecting to go to a different destination, and why the family was expecting a different company. The staff wanted to know if we could transport this patient, and we did check with our dispatcher, but since a different company was supposed to be doing it, we had to get her off our stretcher and put her back in her bed. By this time, we had already been in the ICU about an hour, and that other company was supposed to be there when we first got there. It turned out that the Pt. we were supposed to be getting wasn't even in the ICU in the first place, and by the time we found her and got her, it was nearly 45 minutes later than that. As we were on the way out the door with our correct patient, we saw a crew from the other company coming in to the hospital, so they were nearly two hours late to pick up our original incorrect patient. I guess the family was waiting at the hospice quite a while, but I'm guessing the Pt. at least survived to the hospice, because I'm quite sure that if she had died away from her family, they would have raised serious hell that we would have heard about.

So I guess I've learned a lesson: Don't trust anybody, always check the wrist band!


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## Ridryder911 (Oct 15, 2007)

Good story.. like to see more paragraphs, much easier to read. 

R/r 911


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## Tincanfireman (Oct 17, 2007)

This kind of thing probably happens more than it should, and it underscores a valuable lesson regarding verification of the patient's identity.  I know that I'll always check the wristband from now on.  Good write-up.


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## DisasterMedTech (Oct 18, 2007)

Good Catch!!! Of course it underscores your point of checking the patient's ID to the greatest extent you can...but I think this one was on the nurse's at the station. As Ive mentioned myself, I was at the ER myself the other day as a pt for what was believed to be a cardiac issue and the X-ray tech wanted pics of my fingers in the position of function. Again I say good catch, lesson learned...but probably not as big as the nurses in the ICU. Somebody's gonna get a spankin!

Seems like the little scanners that you can scan a page at the nurses station and then the pts wrist band with would be more common. Makes you wonder how many parents end up with babies they didnt make themselves. "Honey...why does our baby look Chinese?....I dont know sweety but all that matters is that we love him."  Good golly miss molly. What were the ramifications when you got back to your station, if any?  Not really your fault, though kinda, but not really, thought kinda, but mostly not really...:blink:


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## VentMedic (Oct 18, 2007)

Even with the wrist bands, I look at the age listed on it. Especially in busy ERs, I have seen wrong bands, wrong patients, wrong ER etc.  For nonverbal patients, another licensed professional must also confirm ID. 

I've actually noticed people wearing a neighboring hospital's gown in our ER. Some well meaning person directs them after a procedure to us from across the street because our ER sign was more visible.


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## Amack (Oct 18, 2007)

Yeah, imaginably so, mix-ups can be scary. :wacko:
Lesson learned: always double check and re-check! 

Great story!


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## BossyCow (Oct 18, 2007)

Ahhh, the beauty of the rural EMS agency.  No problem identifying the patient here... "Hey, that ain't Joe!"


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## SarahTAAS (Oct 24, 2007)

You pretty much have to check everything when it comes to The ER.  Our hometown ER had a different pt blood hanging on our pt.  Thank God we noticed it before the Ambulance pulled out of the bay.  It ended up being the same blood type so the pt was fine. BUT STILL!!!


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## Getnjgywitit (Oct 24, 2007)

Thanks for posting the story!  Great lesson!


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## MMiz (Oct 24, 2007)

I went to the wrong room once, starting getting my vitals and chatting it up with the pt.  It was only after I checked the pt's ID that I realized I was in the right room, but on the wrong floor.

Lesson learned


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