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Strategy Submission

Patient Safety Teaching Case - Wrong Patient Procedure


Leslie W. Hall



Associate Professor of Clinical Internal Medicine


Kathryn J. Nelson, MHA; Director of Quality and Patient Safety; SSM St. Mary’s Health Care


University of Missouri - Columbia


Competency Categories:


Learner Level(s):

Pre-Licensure ADN/Diploma, Pre-Licensure BSN

Learner Setting(s):

Clinical Setting

Strategy Type:

Online or Web-based Modules

Learning Objectives:


Examine human factors and basic safety design principles as well as commonly used unsafe practices as they relate to an adverse event in health care. Describe the benefits and limitations of information systems in the improvement of health care quality. Discuss effective strategies to improve reliability of patient identification in delivery of health care.


Value the balance between professional autonomy and standardization or reliability. Appreciate the cognitive and physical limits of human performance. Recognize the value of engaging in root cause analysis rather than blaming when error or near misses occur. Value relationship between national patients safety campaigns and implementation in local practices settings.


Use appropriate strategies to reduce reliance on memory. Demonstrate an effective use of strategies to reduce risk of harm to others. Participate appropriately in analyzing errors and designing systems improvements.

Strategy Overview:

The attached case describes an adverse event in which the wrong patient with a similar sounding name was contacted and asked to come to the hospital for a procedure. Although the patient did not suffer any permanent harm from this event, the patient did experience inconvenience and minor discomfort, and the involved health care workers and system suffered significant embarrassment. In reviewing this case, nursing students are challenged to look beyond blaming one or more health care workers for this mistake, and instead identify system issues (latent factors) that led to the environment where such an event could occur. They are then challenged to identify possible system interventions that might lead to safer systems of care in the future. We have utilized this primarily in small group settings (some single-specialty, some interprofessional), usually in the format of a simulated root cause analysis. However, this case could also be utilized for computer-based training.

Submitted Materials:

Additional Materials:

Evaluation Description:

Learner evaluations of sessions in which this teaching case has been utilized have indicated that the case was felt to be helpful in learning important patient safety principles.
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