Published Apr 30, 2011
jschex6
37 Posts
I am starting nursing school in the fall and had an experience today that I thought I would share as a reminder to all on how careful one must be with putting results in a patient's chart.
I had an OB/GYN appt. back in Sept for a routine pap smear. My doctor called me Thursday to say that my results were abnormal and that he wanted me to come in for a colposcopy. I have had abnormal paps in the past and colposcopies so it didn't really come as a surprise. What did surprise me is that my appt. was back in Sept and they were just now calling me. I know they are a high volume, busy office with 5 doctors totally but to get results 7 months later? I was definitely going to address the issue when I went in for my appt. Well I showed up yesterday for my colposcopy and I am undress waiting in the room. I have had many medical problems in the past and move around alot, so I always get copies of my medical records and keep everything in a binder. I told the nurse I would like a copy of my most recent pap smear. She made me a copy and told me the doctor would be in shortly. When I got up to look at the pap results, I notice the abnormal pap smear belonged to someone else and NOT ME!!! We had the same first and last name spelled differently, different dates of birth, different collection dates and in fact different doctors. When my doctor came in and asked "how I was doing today" I told him he had the wrong patient for his colposcopy today. Needless to say he was extremely angry and I think his whole office got in trouble. I used to work in doctor's offices and I realize how mistakes can be made and that no one is perfect. It was scary to think though that I almost had an invasive procedure for no reason and that no one would have caught it. Plus the poor girl that needs it hasn't even been notified. What also worried me most is that I thought I had gone 7 months with an abnormal pap smear.
In the end, no harm was done and I still love my doctor. I just wanted to share my story as a reminder that we always need to take our time and pay attention to details to make sure that mistakes like this don't happen. No one is perfect but please take the time to make sure you have the correct patient.
netglow, ASN, RN
4,412 Posts
Moral of your story is really for you. You won't forget this now when you begin to pass meds in your very first clinical. It's called the 5 rights, and it's applicable for everything you (do), really in some form of it.
Double-Helix, BSN, RN
3,377 Posts
Good for you for being your own advocate! There is certainly a lesson here for many people.
Not to mention the huge HIPPA violation that occured when they handed you someone else's medical report with all of her personal information... No wonder they were mad.
nurse2033, MSN, RN
3 Articles; 2,133 Posts
Thanks for sharing!
rkitty198, BSN, RN
420 Posts
Wow! That is really awful. I would have been ******.
Reminds me of picking up my prescription from the pharmacy and everything on the bottle was right except that I knew I was not prescribed effexor. They had the wrong drug entered for me. I was in nursing school at the time, as before I wouldn't have paid attention and probably would have taken it.
Mistakes happen, that is why, as a patient, we need to be our own advocates for ourselvs and our families.
CharcoalPepper
46 Posts
Thanks for sharing this story. It shows how easy mistakes can be made when patients have similiar information and the need to verify and verify again.
roser13, ASN, RN
6,504 Posts
As always, I think about elderly patients (our parents and grandparents) who likely live with many, many mistakes made in their medical records. Sometimes it's all they can do to get themselves to the dr's office routinely, take their pills daily and follow other medical advice. They certainly don't always have the wherewithall to police their medical records as we all know should be done.
I'll never forget finding a mistake in my husband's medical record. Our new pulmonologist was treating my husband very cavalierly (in my opinion) and did not seem all that vested in working toward a good outcome. I thought it was just his bedside manner but later realized that the transferred records from the previous pulmonologist stated that my husband continued to smoke despite a very dire diagnosis. That statement in the former Dr's dictation was completely false and I have no idea how it got there. Should that have made a difference in the Dr's attitude toward my husband? Probably not, but I'm betting that it did.
Black Jade, BSN, RN
282 Posts
jschex6: Unfortunately I have seen many of these mistakes happen when Medical Records will file the patient's results in the wrong chart.
Esme12, ASN, BSN, RN
20,908 Posts
Lesson learned for all........and one I'm sure you'll fnd very valuable as you continue in your career....
CrissiQ
54 Posts
Wow, and very smart of you to ask for a copy of the lab result!
1southernstudent
125 Posts
It happens more than you think. It happened with my parents medications all the time. Their first names were similar and their initials were the same so the pharmacy would get them mixed up on a pretty regular basis. When they called in for a doctor's appointment they would make it for the wrong person. Imagine my surprise last month when I picked up my dad's prescription and it was labeled for my mom. She's been deceased for 8 years but apparently there is another lady with the same name in the community and they mixed up her medicine with my dads.
I also had a huge battle with the pediatrician's office over billing my insurance for visits for a child that had the same name as my son. They started sending me bills for copays and noncovered expenses that weren't ours. This child had been very sick with several visits and hospitalizations and mine had only had well baby visits that were covered. When we finally figured it out they had been doing it for over a year. It was such a mess that I changed doctors and they tried to refuse to forward his medical records until I paid the bill. I took me threatening a lawsuit to get it cleared up.
Not_A_Hat_Person, RN
2,900 Posts
I went through something similar about 7 years ago. I was about to finish my English degree, and I wanted to get some things done before my university health insurance ended. I went to Health Services for a tetorifice booster. They sent me to a room. Within 5 minutes, someone came in, took my blood pressure, gave me a robe, told me to undress, and said the NP would be in shortly. When I told him I was there for a tetorifice booster, he looked very surprised, then moved me to a different room.