Patient Identification -- Content for Hospital Newsletters, Safety Huddles, Etc
A few weeks ago, a risk manager friend asked if she could use my brother's story in her hospital's internal/staff newsletter. The risk manager said that patient mis-identification is a concern at her hospital, and my brother's story might be impactful with her staff. Last week the newsletter was released and it was wonderful.
I was happy to share the story with my friend and her colleagues, and now I share the text that was used in that hospital newsletter for you to consider sharing in your own staff newsletter, safety huddles, or through other means (see below). I only request you reference Sorry Works.
Unfortunately, patient misidentification is a prominent and chronic problem with potentially tragic consequences. Hopefully sharing this part of my brother's story will save lives, and reduce the need to say "sorry." Here you go....
Hospital Newsletter/Safety Huddle Content
Patient Identification. Sounds like a bland yet common sense term that shouldn’t be controversial or problematic. After all, we know the identities of our patients, correct? What happens, however, when, because of a distraction or fatigue, we don’t know the patient? We misidentify the patient?
I hope you will remember my family’s story and never let patient misidentification happen on your watch.
At 2am in the morning of May 5, 1998, my brother, Jim, presented to an ER in Cincinnati, OH with chest, shoulder, neck and stomach pains so severe it roused from his sleep. Jim had all the classic signs of a heart attack; however, the attending physician thought Jim only had a stomach ache, never drew blood, administered an ulcer cocktail, and discharged Jim a couple hours later – still in extreme pain. Later that morning my parents brought Jim back to the same hospital (by then Jim was losing consciousness). This time the ER drew the blood and sure enough the enzyme was in the blood indicating damage to the heart muscles.
Jim was admitted to the ICU, but the computer monitors over his bed read, “Ray Wojcieszak.” Who is Ray? That was our father (he passed in 2016). Dad alerted the medical staff of the potential mix-up, and the doctors and nurses actually argued with dad about who was who. Only when dad pulled out driver’s licenses did the disagreement end. The computer monitors was changed to read “Jim Wojcieszak,” but they were still using our dad’s chart.
Dad had been a patient at this same hospital for a stress test a couple months prior to Jim’s admittance. Dad passed that stress test with flying colors; the cardiologist said he “knocked the machine off the wall.” In our lawsuit we learned that the hospital staff mistakenly used dad’s chart to form a diagnosis of a bacterial infection of Jim’s heart instead of a heart attack (the autopsy showed he had two to three heart attacks under the care of the hospital). For two days the hospital plugged Jim full of antibiotics only to watch him decline. The last afternoon of Jim’s life he was severely swollen, coughing up blood, and in terrible pain. Someone decided to run a probe up his leg and they found major blockage in the arteries of Jim’s heart. Jim crashed during the test and died during emergency open heart surgery.
Our family was shattered by Jim’s death, and his death still continues to inflict damage 23+ years later. I can only imagine how the doctors and nurses involved in Jim’s care have coped; this is the type of case that creates 2nd victims.
This tragic story happened because someone was in a hurry, distracted, or fatigued, grabbed the wrong chart, and didn’t double-check. Someone didn’t make sure to know the identity of Jim Wojcieszak. The doctors and nurses mistakenly believed they were treating Ray Wojcieszak.
I know physicians and nurses are stretched to the limit with the pandemic. You have seen nothing but death and destruction over the last two years. For your sake and mine, don’t add to the sadness and tragedy by misidentifying a patient. Always remember Jim Wojcieszak when you grab a chart. Remember Jim when you take a second to double-check the identity of your patients. Don’t let this mistake happen on your watch.
God bless you in your work and stay safe!
Doug Wojcieszak, MA, MS, is the Founder and President of Sorry Works, the nation’s leading advocacy and training organization for disclosure and apology. Doug founded Sorry Works! following the death of his brother, Jim. Doug can be reached at doug@sorryworks.net or 618-559-8168.