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Nov. 12 09 CNN – How to avoid falling victim to a hospital mistake

How to avoid falling victim to a hospital mistake

When Kerry Higuera started bleeding three months into her pregnancy, she feared she was miscarrying. Heading to the emergency room seemed like the prudent thing to do.

Higuera says she’ll regret that decision for the rest of her life.

When Higuera arrived at Banner Thunderbird Medical Center in Glendale, Arizona, that February morning in 2008, she was put in a room and told to wait for a nurse to come get her. Soon, a nurse poked her head into her room.

"She said, ‘Kerry?’ and I said, ‘Yes,’ and she said, ‘I’m going to take you for a little walk’ and I followed her down the hallway," says Higuera, a mother of four who lives in Peoria, Arizona.

"She brought me to the CT scan room, and I said, ‘Is this really what I need to have done?’ And the nurse said, ‘Yes, this is what the doctor wants. He wants a CT scan of your abdomen,’ and I said, ‘OK,’" Higuera remembers.

After the scan, the nurse led Higuera back to a room to wait for the doctor.

"I was so scared. I told my husband, I’m sure I’ve had a miscarriage. I’m sure the doctor is going to come and tell us we lost the baby," she says.

But that wasn’t what happened at all.

After about half an hour, Higuera says the emergency room physician, two radiologists and a representative from the hospital’s human resources department came into her room.

"I started to cry and asked if I’d miscarried, and they said no, I was still pregnant. My husband and I said, ‘Oh, that’s great!’" she remembers.

But then they told the Higueras there was something else they needed to know. "They said, ‘We made a mistake; we did something we shouldn’t have done,’ and I was like, ‘What do you mean?’" Higuera remembers. "They said ‘There’s another patient here named Kerry, and you two are the same age. We mixed you up. She was supposed to have the CT scan, not you.’ "

While no large studies have been done on the effects on the fetus of performing a CT scan to a pregnant woman’s abdomen, experts say a fetus exposed to radiation can, in some cases, develop physical and mental growth problems

In statement e-mailed to CNN, Bill Byron, senior director for public relations and online services at Banner Health, wrote, "Ms. Higuera is represented by legal counsel in this matter and it appears to be moving towards litigation; therefore, Banner Health is unable to provide any comment at this time."

Higuera’s lawyer, David Patton of Scottsdale, Arizona, provided CNN with Higuera’s records from her visit to Banner Thunderbird. "The patient was unintentionally scanned as she was confused with another patient," reads one report.

"There was a misidentification of the patient and inadvertently this patient [Kerry Higuera] had a CAT scan of the abdomen and pelvis performed," reads another report. "[The scan] had been ordered for another patient with a similar first name."

More than five wrong surgeries every day

While Higuera’s story is certainly unusual, it’s more common than you might think for a hospital patient to be the victim of mistaken identity, or to receive a surgery on the wrong body part.

The Joint Commission, which accredits hospitals, reports that wrong-site, wrong-side and wrong-patient procedures occur more than 40 times each week in the United States.

Earlier this month in Rhode Island, state regulators took the unusual step of requiring video cameras in all operating rooms at Rhode Island Hospital after a spate of errors.

At least six surgical errors have occurred at Rhode Island Hospital since 2001, including one where a child went in for eye surgery and the surgeons, confusing this child with another patient, took out the tonsils instead.

Another child had cleft palate surgery on the wrong side of the mouth. Another patient went in for neurosurgery, and doctors drilled holes on the wrong side of the head.

Dr. Mary Cooper, chief quality officer for Lifespan Health System, which owns Rhode Island Hospital, says the facility is fully committed to making the hospital safer.

"Every single time we hear of something we can do to prevent problems, we put in those fixes," she says. "We like to catch all errors before they happen, and we do a good job of that, in general."

She added that just because surgical errors occur at a hospital does not mean that the hospital is bad. "I was working at a hospital where my husband had an operation in the wrong location, and he continued having surgeries there," she says.

Free coupons and flowers

Back in Arizona, Higuera says the doctors were "very nice" and "said they were sorry over and over again."

She says the emergency room doctor, who was also pregnant, cried as she apologized to her and her husband. "They asked me if I wanted free coupons to the hospital cafeteria, and I said no thanks. They asked me what kind of flowers I liked, that I would have flowers waiting for me when I arrived home," she says.

Higuera says the doctors explained to the couple that their baby could have mental retardation, a low IQ or growth problems because of the radiation exposure.

Her baby, Nathan Higuera, is now 15 months old. His pediatrician is aware of Nathan’s situation, according to Nathan’s medical records, given to CNN by Higuera’s lawyer.

"MOM EXPOSED TO RADIATION DURING FIRST TRIMESTER," reads one comment in the pediatrician’s notes. "CHECK DEVELOPMENT!!!"

In the pediatrician’s records, it’s noted that at 3 months of age, Nathan’s head circumference had been in the 73rd percentile, but that at his 1-year checkup it was in the fifth percentile. Pediatricians often consider it a red flag if a child’s growth does not stay in the same percentile range.

The records also note that Nathan would be referred to a specialist soon if his growth and development "is not that great."

"I feel horrible that I let them do the CT scan," says Higuera, crying. "But I thought the doctors must know what they’re doing. I didn’t know. I didn’t know."

To try to keep yourself and your family from receiving the wrong surgery, follow the advice below. As Jim Conway, the senior vice president of the Institute for Healthcare Improvement puts it: "An empowered patient becomes a very important partner in getting things right."

1. Say: "My name is Mary Smith, my date of birth is October 21, 1965, and I’m here for an appendectomy."

You might feel like an idiot, but say this to every doctor, nurse, and technician who takes care of you.

2. Say: "Please check my ID bracelet."

Hospital staff is supposed to confirm your identity in at least two ways, according to Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. One of those ways is to check your ID, or scan it if it has a bar code. Another way is to ask you for your name and date of birth.

Of course, you should check your bracelet to make sure the information on it is correct.

3. Say: "Please look in my chart and tell me what procedure I’m having."

If a nurse states that you’re having an appendectomy and she’s right, that’s not enough, because that nurse won’t necessarily be there with you in the operating room.

"Make sure the nurse is looking at your chart when she tells you what procedure or test you’re having," says Ilene Corina, president of PULSE, New York, a grass-roots patient safety organization.

4. Say: "I want to mark up my surgical site with the surgeon present."

Hospitals these days often hand patients a pen and ask them to mark where they’re going to have surgery. Corina says you should do it in front of the surgeon who will be with you in the operating room, and not just in front of the person who hands you the pen.

"If you mark it and the surgeon doesn’t know about the marking, what’s the point of marking it?" Corina asks.

5. Be impolite.

Foster, the executive at the hospital association, gives this example.

"If the nurse comes in and says, ‘Are you Mary Jones?’ and you’re really Miriam Jones, you might just nod your head and say yes because you’re too polite to correct her," Foster says. "Don’t be polite."

Higuera now wishes she’d been impolite and followed her instincts.

"On my way into the CT scan, the nurse looked at the chart in her hands and said, ‘This scan should help tell us why you’re having abdominal pain.’ I told her I wasn’t having pain, just bleeding, and she said, ‘Well, the doctor says you’re having pain,’ " Higuera remembers. "I thought it was strange, but I didn’t say anything more."

It was, of course, the other Kerry who was having pain, the Kerry who actually did need the abdominal CT scan.

"If that happened to me now, I would say, ‘Stop everything, I’m not doing this scan,’ " she adds. "If I were wrong, I’d have been embarrassed. But I’d rather be embarrassed than be in the situation we’re in now."