What happens when doctors and nurses treat the wrong patient

As a former hospital administrator, I remember the focus that we placed on new accreditation standards announced each year by the Joint Commission. Every time the new standards were released, we rushed to write and implement new policies and procedures to implement them at our hospital. This annual process made me a firm believer that the best way to get something done is to set clearly-measurable goals.

The Joint Commission is the oldest organization that accredits hospitals and healthcare facilities. Based on its detailed standards and site visits of accredited hospitals, it has unique perspective to see trends and challenges in patient care.

Applying this information, the Joint Commission announces several “National Patient Safety Goals” each year, with the aim of setting the bar higher when it comes to common errors or challenges in healthcare.

Identifying patients correctly.

In 2017, two National Patient Safety Goals address the importance of identifying patients correctly. Goal 01.01.01 requires hospitals to, “Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.” Goal 01.03.01 mandates that hospitals, “Make sure that the correct patient gets the correct blood when they get a blood transfusion.”

While at first glance, it seems that misidentifying patients would not be such a major problem that would necessitate to National Patient Safety Goals to help remedy it. On closer consideration, though, it makes sense, in that hospitals are busy places, with lots of patients, and many healthcare providers involved in the delivery of care. In other words, it is a setting that is ripe for human error.

In my practice as a Houston, Texas medical malpractice attorney, I have handled numerous cases where human error and handling medications has been an issue at hospitals, nursing homes, skilled nursing facilities, and rehabilitation hospitals.

Just the other day, I met with a couple whose newborn baby is hospitalized in a neonatal intensive care unit (NICU) in a major hospital in the Texas Medical Center. They generally spend all day every day with their baby, but on one recent occasion were away for the evening and called a nurse for an update. The nurse gave them a long and detailed report on the lab work and condition of a different baby who had a similar medical condition.

On many other occasions, I have patients who are seriously injured as a result of another patient’s medications being given to them. In each case, both of the patients involved had correct physician orders for medications, which had been properly filled by the pharmacy, but they were mistakenly switched by the nursing staff.

As you can imagine, this can be quite dangerous, depending on the medication. The wrong drug can be contraindicated with another medication that the patient is properly taking, leading to a life-threatening situation. Other times, the dosage of the wrongly-given medication can be too high for patients, causing them to go into cardiac or respiratory arrest.

While medication errors like this are supposed to be reported and documented in both patients’ medical records, that does not always happen. These occurrences are sometimes reviewed at a hospital committee level, which is shielded from discovery or review by the very hospital-friendly Texas hospital committee privilege.

What you can do

While I commend the Joint Commission for implementing two 2017 National Patient Safety Goals on identifying patients correctly, there are some additional things that you can do to improve your own safety.

First, I recommend keeping a healthcare journal. Write down useful information, including the names of physicians and nurses, radiology orders, lab test orders, and prescriptions or medication orders. For each order, note the date and time it was made. Your journal will help you keep track of information as to tests and medication orders that are pending, so you can follow up on obtaining answers and results.

Second in the context of medication errors, I recommend that patients interact with nursing staff when they come to the room to administer medication. Using information from your healthcare journal, you can politely ask what medication is being changed or given. This provides an extra layer of protection to ensure that you are receiving the correct medication.

If you or someone you care for has been seriously injured as a result of medical negligence, call the experienced malpractice attorneys at Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case.


Robert Painter is an attorney at Painter Law Firm PLLC, in Houston, Texas, where he represents patients and family members and medical malpractice and wrongful death lawsuits against hospitals and physicians. Painter Law Firm PLLC was recognized by the Better Business Bureau, in 2017, with an Award of Distinction.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.