Here are three cases of registration errors that were reported to ECRI Institute, a Plymouth Meeting, PA-based organization that researches approaches to improving patient care:
- A registrar selected the incorrect doctor from two physicians with the same last name.
This mistake resulted in the wrong doctor’s name being placed on the sticker on the chart and the patient consent. “This was then scanned, providing wrong information to pathology. The report was sent to the wrong doctor,” says Bill Marella, director of patient safety reporting programs at ECRI Institute.
- A registrar at an urgent care center inadvertently entered the patient’s information into a different patient’s account with the same name.
“Entering a new patient’s information on the old account actually changed the information for the other patient as well,” says Marella.
- A patient’s previous weight was used to calculate drug dosages, instead of the patient’s current weight.
“Frequently, information changes between admissions, and some of it is pretty significant,” says Marella. An oncology patient’s weight was accurately captured in the registration system from a previous visit. However, the patient had lost a significant amount of weight since then. “The pharmacist used the previous weight to calculate the dose and injured a patient pretty severely,” says Marella.
The nursing notes reflected the patient’s change in weight, but these were not available to pharmacy. Instead, the information in the registration system populated the pharmacy system. “People calculate the doses of some pretty dangerous drugs based on the patient’s weight,” says Marella. “Sometimes, that’s the only information that ends up being available to the pharmacy.”
- Outdated demographic information was carried forward from a prior admission.
An elderly patient was brought to the wrong location because outdated demographic information was carried forward from a prior admission. The address given to the ambulance service was incorrect.
“This highlights the risk of registration systems which copy information that was current at the time of the patient’s last admission forward to the new admission,” says Marella.