Hospital Gone Mad?

by Tiffany Lauria

In a recent court document[1] , filed against Dimensions Health Corporation, Joseph and Felicia Ann Wheeler allege that while recovering from auto accident injuries at Prince George’s Hospital Center, Mr. Wheeler was misidentified as a female cancer patient 13 years his junior that was scheduled for chest tumor surgery. In the disturbing events that ensued, Mr. Wheeler’s complaint includes physical assault and battery, false imprisonment and infliction of emotional distress.

While the egregious complaint cannot be stated as fact until the matter is settled, a read through the actual complaint brings up multiple areas in which hospitals, indeed all facilities, could benefit by reviewing their operating procedures and more importantly, the extent that these procedures are followed. Two obvious areas of risk  highlighted by the complaint are as follows:

1. Patient Identification Protocols: From his first contact with clinical staff, right down to his interactions with hospital security, not only did staff neglect to check Mr. Wheeler’s ID bracelet, but upon checking and finding a female name, a nurse failed to exhibit common-sense and flag concern over the patient’s identity. A physician brought in to answer the patient’s questions was apparently upset over Mr. Wheeler’s ignorance of the surgical procedure and as a previous nurse did, failed to check Mr. Wheeler’s ID bracelet. The next time Mr. Wheeler states someone at the hospital checked his ID bracelet was following a period of alleged battery at the hands of hospital security.

Some things to consider when reviewing your organizational policies:

– Does your protocol contain enough checks and balances to ensure that the right identification bracelet is placed on the correct patient from the beginning?

– Are there mandatory sign off sheets or tick screens for clinical staff to mark identity checks completed with each interaction?

– Does your protocol also include physicians, obliging them to check patient identification with every patient interaction?

A proper identification protocol will include each of the aforementioned, as well as stated consequences for staff and physicians not performing up to task, the dates of training sessions completed on the importance of correct identification procedures, and proper procedures for following up on any concerns or deviations.

Remind your staff that common sense should always prevail, and the hospital would rather conduct an investigation into correct identity, than defend itself against allegations of misconduct or malpractice. Make that part of your organizational culture – safety comes first.

2. Incidence Response Protocols:

Mr. Wheeler indicates that as soon as he walked out of his exam room to leave the hospital, nursing staff began to argue with him and call for security. The two officers that responded, according to the allegations, immediately unleashed a barrage of physical abuse and verbal expletives in their attempt to hold the patient against his will in the hospital. This abuse subsequently continued through an interaction with the ranking Lieutenant, the apparent wrestling of a cell phone out of Mr. Wheeler’s hands as he attempted to call 911, and culminated in a hospital administrator begging Mr. Wheeler to stay and promising to provide Mr. Wheeler with a private room and any medications or pain killers that he requested.

One has to wonder about the sensitivity training provided to the security staff in dealing with patients, whether they are leaving against medical advice or truly combative. Regardless of whether your facility contracts out for security or hires in-house, it ultimately falls to you to ensure that all personnel have undergone extensive background checks and targeted training on dealing with your patients and their family members. At one point during the alleged physical abuse, Mrs. Wheeler was prohibited from being with her husband and told she could not enter into an elevator with her husband and the two security officers.

Incident training encompasses much more than security, however. Your Incidence Response Manual must be reviewed and updated annually, with revised versions of protocols and documentation logs, and emergency contact information for management and legal staff. A well-done manual is not only written with legal assistance, but final approval on all revisions must be approved by an attorney familiar with healthcare law. Staff training should include all clinical, administrative and ancillary personnel and it is highly recommended that drills be enacted for various situations.

Oh, and regarding the administrator offering patients any drugs or pain killers they want? One word- Don’t.

As Mr. Wheeler’s complaints play out in the judicial system, there will likely be some more points to be gleaned on how not to run hospital operations. In the end, it would benefit all facilities to take a good, hard look at what you have down on paper, and what really happens when things go awry.