Reference no: EM133567042

Case: A Near Miss for Mrs. Bell

Ninety-year-old Mrs. Bell enters the hospital for a routine replacement of her heart implantable device, i.e., her pacemaker, which is ten years old. She is cognitively sharp, articulate, and in excellent health-other than needing a new device. Upon admission, the clerk places Mrs. Bell's paperwork next to a different set of documents for a patient who is also scheduled for a procedure in the OR. Joe, the transportation team member who is assigned to move her from Admissions to the OR, was late to work today and received a reprimand from his supervisor. Joe is angry, in a rush, and grabs the wrong set of papers. He races Mrs. Bell to Pre-Op without checking her armband. When Mrs. Bell arrives, the OR Admissions clerk reads the papers and says, "Mrs. Jones?" and asks her date of birth. Mrs. Bell does not respond, so the clerk assumes the elderly woman is demented, and sends Mrs. Bell along to what she believes is the next step in the procedure the other patient was in for-a colonoscopy. The OR Nurse barely glances at her armband while looking at Mrs. Jones's paperwork and asks Mrs. Bell if she completed her bowel prep. Mrs. Bell says, "Why would I need a bowel prep?" The OR Nurse, speaking in a tone of voice reserved for children, explains why a bowel prep is needed for a colonoscopy. Mrs. Bell raises her voice and says, "I'm not here for a colonoscopy. I'm here for my pacemaker." The Nurse Manager, who happened to be rounding at that moment, hears Mrs. Bell and steps into the curtained area and asks, "Is there a problem?" Mrs. Bell says, "You bet there is." The Nurse Manager looks at the paperwork and the patient armband and realizes a mistake has been made-in fact, several mistakes.

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