In March 2006 a patient (who we’ll call Patient A) reached an exciting milestone. She had just completed radiation treatment for a brain tumor. However, she was not told that her radiation therapy was complete. Instead, the therapist opened the medical chart of another patient (Patient B) and left. Another therapist came in, saw the chart for Patient B, and noticed that Patient B required radiation treatment for breast cancer. The therapist then delivered that radiation to Patient A.
This incident impacted the facility’s patient safety goal, because of the risk of injury to Patient A. Additionally, it impacted the patient service goal, because Patient A received unnecessary radiation. The organization and compliance goals were also impacted because of this reportable error.
How did this happen? Patient A was at risk for injury because of the delivery of unnecessary radiation. She was given radiation meant for another patient because the therapist delivered the radiation and Patient A, not knowing that her own treatment was complete, didn’t know to stop it. The therapist did not effectively verify the identity of Patient A, instead going off the chart that had been opened by the previous therapist, for unknown reasons. Had the first therapist told Patient A that her therapy was complete, or had the first therapist not opened another patient’s chart, or had the second therapist verified the identity of Patient A, this error would probably not have occurred.
Based on the causes of this incident, we can develop action items to be taken by the facility to reduce the risk of this type of incident happening again. Therapists should not open charts until they have verified the identity of a patient. They should verify a patient’s identity before treatment, and they should review the outcome of a treatment with the patient. After all, had any of these steps occurred, Patient A would have been able to properly celebrate the end of her radiation therapy, rather than worry about a risk to her health.
Step 1 to avoid radiation therapy errors: verify the WHO – the identity of the patient.