It was a routine night on call. The medical team were contemplating turning in for the night when, as usual, the cardiac arrest bleep shattered our calm. We charged up to one of the surgical wards to find a not unusual scene. An elderly patient was undergoing basic life support from the nursing staff. The team assembled around the patient and got to work with advanced life support. At this point all was going according to plan.
At our request, the patient's current notes, old notes, and drug chart duly arrived, and we then made a hurried assessment of the patient's diagnosis and likely prognosis. At this point, I (NKS) felt a growing unease in the pit of my stomach: from the notes I learnt that the patient was due to go home soon, having recovered from a bad case of diverticulitis. However, we continued with our resuscitation attempt. Further alarm bells started to ring when we noted that her drug chart included regularly prescribed opiates and nebulisers, but nothing was mentioned about this in the notes.
Trying not to get too bogged down in details, we (the cardiac arrest team) decided to concentrate our efforts on the patient rather than the notes (which was the easier course of action). Unfortunately, our efforts were in vain, and the patient died. The ward staff and members of the arrest team were duly thanked for all their efforts, and, having recorded the resuscitation attempt in detail in the notes, we dispersed to various parts of the hospital without a second thought.
About half an hour later a distressed nurse practitioner bleeped me to say that there had been a terrible mistake. The family of the deceased patient had arrived on the ward to find their loved one sitting up in bed with a cup of tea, alive and well. It quickly transpired that during the arrest we had used the drug chart of the patient who had died, but the notes were of the patient in the adjacent bed.
Fortunately, the family of the unharmed patient were very understanding, being more relieved than anything else. The patient who died, we soon learnt, was in the terminal stages of her disease. The immediate aftermath was to start “finger pointing” at who could have prevented the mistaken identity, but on more careful analysis it became clear that any number of people could have checked the patient's name band and the records that had been passed to the arrest team in error.
Everyone involved has learnt a valuable lesson, and steps have been taken to avoid a recurrence. The clinical risk team were instrumental in bringing the details together and reconstructing events. Their valuable input also stimulated us to use this lesson at hospital staff rounds in order to pass on this salutary message.
So at your next cardiac arrest, who is going to check the name bracelet?