5. An open hear invasive surgery...on the wrong patient
Joan Morris (a pseudonym) is a 67-year-old woman admitted to a teaching hospital for cerebral angiography. The day after that procedure, she mistakenly underwent an invasive cardiac electrophysiology study. After angiography, the patient was transferred to another floor rather than returning to her original bed. Discharge was planned for the following day. The next morning, however, the patient was taken for a open heart procedure. The patient had been on the operating table for an hour. Doctors had made an incision in her groin, punctured an artery, threaded in a tube and snaked it up into her heart (a procedure with risks of bleeding, infection, heart attack and stroke). That was when the phone rang and a doctor from another department asked “what are you doing with my patient?” There was nothing wrong with her heart. The cardiologist working on the woman checked her chart, and saw that he was making an awful mistake. The study was aborted, and she was returned to her room in stable condition.