A Standardized checklist for hand overs of care between units?

The Wrong Patient. Does the clinical site have a standardized checklist for hand overs of care between units? Do they include a checklist patient identification and the plan of care?

A 67-year-old woman (Patient 1) was admitted through the interventional radiology service for a cerebral angiography. Following the angiography, the patient was transferred to the oncology floor instead of returning to her original bed in the telemetry unit. The next morning, the patient was mistakenly taken for an invasive cardiac electrophysiology (EP) study. Approximately 1 hour into the procedure, it became apparent that she was the wrong patient.

The series of events that led to this wrong patient incident:

A 77-year-old woman (Patient 2) was admitted to the telemetry unit to undergo the EP study. This patient’s name was similar to Patient 1’s name.

When the EP nurse called for Patient 2, the telemetry unit nurses confused the two patients’ names and mistakenly told her that Patient 2 had been moved to the oncology floor.

The oncology nurse took Patient 1 to the EP lab even though there was no written order in the chart and the patient said she was not aware of the plans for this procedure.

The EP fellow decided to proceed even though there was no consent form and a lack of pertinent information in the chart. He discussed the procedure with Patient 1 and obtained consent.

The neurosurgery resident making rounds did not find Patient 1 in her bed and was told she was in the EP lab. He assumed the attending physician had ordered the procedure.

The EP attending arrived but could not see the patient’s face because her head was draped, so he assumed this was Patient 2.

The EP charge nurse noticed that Patient 1’s name did not match any of the names on the morning log. She assumed that the patient had been added after the schedule was distributed.


An interventional radiology attending went to Patient 1’s room and discovered her missing. He called the EP lab and informed them of the error. The procedure was stopped and Patient 1 was returned to her room.

What do you think is the key takeaway from this case study?