The 6 Rs – Right Patient

Of the 6 R’s EMS personnel may think the Right Patient doesn’t apply to us. After all, it is not like we are charged with giving medication to a ward full of patients. We are dispatched usually only for one patient at a time. When we arrive on scene, we are pointed to our patient. We assess the patient and treat according to our findings and take the patient to the hospital. Our patient is rarely if ever out of our sight.

Let me tell you about a hypothetical call. You are dispatched for altered mental status at an assisted living facility. A staff member directs you to the first room on the right where you find an elderly woman laying unresponsive on the carpet, cool and clammy with snoring respirations. Her blood pressure is 138/70 and her heart rate is 80. The lighting in the room is not very good and on quick glance the woman has poor IV access. After repositioning her airway and applying oxygen you make the decision to put her on the stretcher and get her out to the ambulance where you can work on her. You are thinking she is may be a diabetic or possibly having a stroke. You make the decision to load the patient and get her out. The staff member has gone to get the paperwork so there is no one to ask about medical history. On your way out the door, you ask again for the paperwork, and the staff member says she will bring it out to you.

In the ambulance, you check the woman’s sugar. The glucometer reads LO, which means less than 20. You manage to get a IV in the woman’s hand and are able to push in an amp of D50. She rouses somewhat and stops snoring. Her skin is warmer. You recheck her sugar and find it to be 54. By now the aide has brought out the paperwork, which you look through. The woman has a history of MI, but does not appear to be a diabetic. She was last seen at three the previous afternoon, almost seven hours ago. You give her a second amp of sugar and she is again more alert, but her speech is somewhat slurred and she is not certain of her whereabouts. She are uncertain if this is normal confusion for her or she has some degree of dementia. Again, the W10 lists alert and oriented as her norm.

At the hospital, you give your report and turn over care.

The next day, you follow up. Here is what the nurse tells you.

“We couldn’t figure out what was going on with your lady. We did a CAT scan, ran every battery of tests, admitted her for observation. The CAT scan was clean – no CVA, but her confusion continued. She wouldn’t answer to her name, and her sugar was all over the place. Then this morning, the assisted living facility calls to see how Mrs. W, one of their residents was doing. I looked through the system. We had no one by that name here. They were certain we did. I told them to call the other hospitals. I looked through our records and the only person from that facility was the lady you brought in – Mrs. K. When they called back insisting we had Mrs. W, I told them we didn’t but we had a Mrs. K from their facility. No, you don’t the woman from the facility said, Mrs. K is sitting right next to me now in her wheelchair eating her cornflakes.”

So what happened? You guessed it. The facility gave you the wrong paperwork. No wonder Mrs. W wasn’t answering to Mrs. K’s name.

While this particular call did not happen to me, I have had similar situations. I have sat in the ambulance outside a SNF, working on a patient waiting for the staff to bring out the paperwork and once they did, glanced at it to see the paperwork was for a woman when I had a man on my stretcher. I have been handed paperwork for one patient and told to take the patient by the door in the last room on the left and done so, only to have the staff chase after me to say I had taken the patient from the wrong room. They had meant I should take the patient from the last room on the right.

Think this only happens at nursing homes. You are on scene at a fall, unresponsive man fell out of a tree. While you quickly backboard the patient and protect his airway, you ask the police officer to get demographics for you. He hands you a page he tears out of his notepad. You stuff it in your pocket. At the hospital, you give them the name and date of birth on the note pad. Only later do you learn that the name you gave the hospital was for the asthmatic the police officer had treated earlier in the day. In his haste, he tore the wrong page out of his notepad, not the fresh information he had gathered from a bystander who knew the patient

What to do? While there are some times, you will not know the identity of your patient, (you will have John or Jane Doe), there are some steps you can take to protect yourself and your patient. If you are given papers for a patient, ask someone to verify that the papers and the patient are a match. “This is Hazel Jones?” If you are on scene in a house or street, try to get a bystander or family member to verify the patient’s name. “This is Robert Jones?”

While we can work in a chaotic environment, it is our job to bring order to that chaos. Sure the assisted living facility bears a large amount of fault for giving the crew the wrong paperwork, but the crew needs a mechanism to help protect the patient from what by all means is not a completely unforeseeable medical error. Now when the staff brings the paperwork out, I have them provide me with a positive ID of the patient. I read the name on the paperwork and say, “This lady is Mrs. G, right? Right?”

3 Comments

  • John Trader says:

    Great article, thanks for posting. The one true way to ensure the exact identity of a patient, without a shadow of a doubt, is to incorporate biometric technology to the patient identification system. It is now being more widely adopted at health care facilities around the world, and also being used more frequently in ambulatory care and emergency environments.

    It’s the most reliable technology available to avoid errors and subsequent catastrophes.

  • tim says:

    During the transport phase of my career, I developed a habit of asking the patient their name, rather than having them confirm it back to me. Plenty of people will say yes if you ask if they are Mrs. Smith, when they are in fact, Mrs. Domalski.

  • Smokesignal says:

    Worse story: I was called to the scene of a pedestrian who had been killed crossing the street outside of a crosswalk. By all reports, she just walked out in front of a car. She had no purse or identification, but she lived in a high rise for elderly people – government housing – and several people identified her, including someone from administration. We took her to the hospital to be pronounced – we did that in those days – and the family came there because they were told that she had been transported by ambulance but not that she had passed. We were in the position of having to tell them. But when they went to the unit to see her, it was not their family member. All the people that had agreed who it was and the administrator of the facility had by some means identified the wrong person. Now, this was decades ago so things were done differently than they are now so don’t judge the situation by the way things are done now. But it was distressing. We never found out who she actually was but she did live there.

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Peter Canning

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  • Comments
    BH
    Assembly Line
    Two of my major hospitals now employ scribes that accompany their assigned MD all day for the sole purpose of recording their H&P with the patient. It not only makes the doctor/patient interaction more... interactive, but since all the scribes have to worry about is documentation and not patient care, the reimbursements for the doctor's…
    2015-08-26 19:17:52
    Patricia Landmesser
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    I agree with these two... thank you for writing. Your work is inspirational, entertaining and down-to-earth informative. Seems it should be a must read for any who are interested in the EMS field. Many Thanks!
    2015-08-22 11:24:54
    A35EMR
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    I just want to thank you for doing what you do. Your book "Rescue 471" is what inspired me to start my career in EMS. I am currently 16 and working for an urban ambulance service as an EMR, and your blog has been really insightful into skills and knowledge that any healthcare provider should…
    2015-08-18 05:38:41
    Foster
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    You're absolutely right. We don't grow if we don't see the outcomes of our work. ...Or at least, we're less likely to grow in the right direction. You're in a pretty good spot to change some of this in your hospital job. Why not set up a system where paramedics can flag patients they'd be…
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    Jon Kavanagh
    #1 Pain Management and Comfort Care
    We comfort and take care of pain when we remember that the patient is a person. A touch on the hand or shoulder, a compassion for his situation, a desire to do the right thing (vs the easy)... We need to be actively turning his bad day into something less lousy, even when the solution…
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