The winter of 1995 combined blizzards with backaches and lots of admissions. Influenza had hit our patients badly, and weekends became marathons of rounding, work-ups, calls, and more rounding. Things started simply enough on the geriatrics floor that winter day. It was Friday night and the sign-out ritual had begun. A few things needed to be checked over the weekend, though most problems were ongoing and could be dealt with on Monday. Finally, my last colleague called and told me about a Mrs. G, whose story was a familiar one in geriatrics. She was very old and sick, and was expected to “go anytime.” The family was expecting her death. I expected the call to come in overnight before I could see her, but that particular night was quiet.
I arrived at the hospital the next morning and went directly to the geriatric floor to make rounds. In between reading the charts, seeing the patients, checking the labs, and talking to the nurses, I often looked out the window to bring me a moment's reprieve. The scene changed from season to season and brought to mind the views that the great Japanese woodblock artists captured long ago of Mount Fuji at different times of the day and year.
Patients, too, have different aspects depending on what time of day one sees them. They are sometimes more alert early with good appetites and then fade or become confused toward sundown. But one of the patients I rounded on, the one signed out as near death, was not in a state of changing landscape. Mrs. G was in that period between life and death we sometimes call agonal and yet assure the family that their loved one is not suffering. There not being much to do to alter the situation, I continued on my rounds.
The patient in the next room, Essie, also had advanced dementia and had been in and out of the hospital with asthma flares and aspiration pneumonias. She was the kind of patient the case managers call a “frequent flyer,” and about whom “long-stay” meetings are convened and endless chart notes are penned. She had pulled out of this, her most recent dive, and though tethered to the room and bed by oxygen and IV lines, feeding tubes and restraints, was beginning again to be delivered from her dyspnea and delirium. I examined her, noted her improvement, and moved on to the next room.
A few minutes later, the charge nurse called me back into Mrs. G's room and showed me the still and breathless form. I confirmed her observation and walked to the nurses’ station to find the chart and call the family. The chart was in the front of the chart rack. I pulled it out and opened it on the table to look for the family's phone number. Before I could find it, I was called to the other end of the nurse's station to answer a question about some other orders. After discussing the situation with the nurse involved for several minutes, I returned to the task at hand and dialed up Mrs. G's family. They picked up after one ring, and I imagined that they had been waiting for hours by the phone for “the call,” would be sad but understanding, and would confirm that they did not want an autopsy. But as soon as I got out my well-rehearsed “I'm sorry, but I'm afraid I have some bad news,” there was a great commotion on the other end of the line. I was perplexed. The confusion grew louder as I could hear the news being passed from person to person and room to room. The crescendo of wails then truly alarmed me and I checked that I had dialed the right number which, peering into the chart, I had. Between sobs, the family insisted that “she wasn't that sick” and that no one gave them “any warning.” I began to wonder about my colleague's sign-out, but when I first examined her, Mrs. G had seemed near the end. Was my delivery so rehearsed that it had become callous? After a few more exchanges I could see there was no way to comfort them. I said goodbye and hung up.
I stared at the chart again and then looked at the name on top. It wasn't Mrs. G's at all. The chart belonged not to the woman who had died, but to the woman with asthma, pneumonia, and dementia — to Essie, the wrong Mrs. G! I then understood what had happened. In the few minutes that I had become distracted and went to the other side of the nurses’ station to look over the other orders, someone had taken out a different chart to use and placed it on top of Mrs. G's chart. I had dialed the wrong family and reported the wrong death. No wonder the cries and the fury.
I immediately redialed the number to the wrong Mrs. G's family. The line was busy — several more tries but busy, busy, and again, busy. Of course, they were calling family, friends, maybe even the funeral director to report a death that Mark Twain would have called “highly exaggerated” — and I was the agent of that death. I had killed her and she wasn't even dead! In the meantime, I was able to find the number of the real Mrs. G's family from the correct chart. I reported to them the passing of Mrs. G and they were understanding and appreciative. I had in a sense come full circle but knew that the damage I had caused remained. I hung up quickly with them and paged our hospital administrator. These many years later, I cannot remember whether he got through to the wrong Mrs. G's loved ones or whether I did, but they were told of the terrible mistake, and a group from social service was dispatched to their house.
Would that this whole episode had never occurred. I would like to think that I could rewind and erase those few careless seconds when I looked into the wrong chart. But I also cannot fail to recognize the irony here that applies to me as a practitioner of geriatrics. There are few true “saves” in this discipline. I often feel like a relief pitcher brought into a blowout game on the losing side to record the final three outs. Here was a chance for a save! Alas, real life saves, much less resurrections, are blue moon material.
As it turned out, Essie wasn't long for this world either; she died several weeks after the incident. Sometimes I look back and wonder whether I had put a curse on Essie. But just as I couldn't change what really happened, I know that I hadn't cursed Essie either. This was medicine and not Italian opera. I tripped and stumbled in an old hospital on a cold winter day. I made a terrible mistake. A patient can live or die by our mistakes, or in this case, die and then live by them. So let me give you a piece of advice: Check the name on every chart you touch — and not just when death hangs in the balance.
Have you ever made an error that had far-reaching implications? Share your experience, and how you got through it, in the comments below.
Dr. Schor is a geriatrician specializing in long-term and post-acute care. He was medical director and attending physician at Daughters of Israel for close to 30 years and is now a Senior Medical Director at Optum Health. He is a new grandfather, an avid birder, and lives in Millburn, NJ.
All names and identifying information have been modified to protect patient privacy.
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