AHRQ Web M&M Examines Challenges in Protecting Patient Privacy

The current issue of AHRQ’s Web M&M features the case of a hospitalized patient with advanced dementia who was to undergo brain magnetic resonance imaging (MRI) as part of a diagnostic workup for altered mental status. Hospital privacy policy dictated that signout documentation include only patients' initials rather than full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment resulting from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error. The Perspectives on Safety section of the issue includes two features about new insights on safety and health information technology. The first is an interview with Robert M. Wachter, M.D., professor and interim chairman of the Department of Medicine at the University of California, San Francisco, about his new book, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.” The second is an article by researchers at Georgetown University Hospital about health information technology usability design.

WebM&M Morbidity & Mortality Rounds on the Web

Cases & Commentaries

SPOTLIGHT CASE

Privacy or Safety?

A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error.
Commentary by John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM

CME/CEU credit available for this case

Breathe Easy: Safe Tracheostomy Management

Admitted to the hospital with sepsis and pneumonia, an elderly man developed acute respiratory distress syndrome requiring mechanical ventilation. On hospital day 12, clinicians placed a tracheostomy, and a few days later the patient developed acute hypoxia and ultimately went into cardiac arrest when his tracheostomy tube became dislodged.
Commentary by Matthew S. Russell, MD, and Marika D. Russell, MD

Baffled by Botulinum Toxin

A 5-year-old boy with transverse myelitis presented to the rehabilitation medicine clinic for scheduled quarterly botulinum toxin injections to his legs for spasticity. Halfway through the course of injections, the patient's mother noted her son was tolerating the procedure "much better than 3 weeks earlier"—the patient had been getting extra injections without the physicians' knowledge. Physicians discussed the risks of too-frequent injections with the family. Fortunately, the patient had no adverse effects from the additional injections.
Commentary by Krishnan Padmakumari Sivaraman Nair, DM