Sentinel Event: Surgical Procedure on the Wrong Patient

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It is noted that wrong patient errors are still common (Sadigh, Loehfelm, Applegate, & Tridandapani, 2015).

Owich Combulo (assumed name) was a 40-year-old woman admitted to a facility for cerebral angiography. A day after her intended procedure, the patient was wrongfully taken for an invasive cardiac electrophysiology surgery.

The patient had been well, but a recent accident left her with a head insult. A subsequent magnetic resonance imaging detected large cerebral aneurysms. As such, the radiologist admitted Ms. Combulo for cerebral angiography. All cerebral angiography procedures were done successfully. After the procedures, however, Ms. Combulo was transferred to the wrong oncology unit instead of her initial bed at the telemetry unit.

The patient was ready for discharge in two days. The next day, however, Ms. Combulo was taken for a cardiac electrophysiology surgery. After about one hour into the invasive procedure, it was determined that she was the wrong patient for the procedure. The procedure was halted and the patient was returned to her ward in a good condition. Ms. Combulo shared her last name with the correct patient for the invasive cardiac electrophysiology surgery.

The barriers to communication identified in the event

The most vital latent conditions – system faults observed were communication failures, teamwork and identification challenges. This sentinel event displayed poor communication, which is particularly common in large hospitals. Physicians did not effectively communicate with the nurses. Attending specialists did not communicate with resident physicians while other care providers from the telemetry unit and oncology unit failed to communicate. In addition, not all care providers listened to the patient while the process of obtaining the informed consent, which could have protected the patient, appeared to be fundamentally flawed.

Hence, communication barriers played a critical role in this sentinel event – an invasive surgical procedure on the wrong patient (Chassin & Becher, 2002).

The nurse administrator’s role in the event and an appropriate analysis of correcting errors to improve outcome

The case depicts a case for immediate and total disclosure of the wrong patient error. The nurse administrator must ensure full honesty, disclosure and inform the patient and families. The nurse administrator is responsible for patient safety and must systematically evaluate the complex dynamics that influence safe delivery of care services (Ballard, 2003).

When the nurse administrator assesses the system to safeguard against wrong patient surgery, they need to ask critical questions to determine the problem with the hospital procedures and policies. In addition, they must assess the system effectiveness on managing built-in redundancies and measures for practitioners to review patient information effectively.

The nurse administrator should determine the right orientation and training processes and ensure that the right care providers participate to meet universal standards.

The nurse administrator must recognize the role of the team and insist on a team approach to develop solutions, particularly on enhancing verification of patient identities.

A risk analysis and/or root cause analysis

According to the Joint Commission, a root cause analysis for wrong patient invasive procedure should include the following elements (The Joint Commission, 2013; Cerniglia-Lowensen, 2015).

First, the individual identification process for the patient was not executed. As such, a wrong patient was sent for a wrong procedure. The hospital should develop unique patient identification processes and procedures rather than relying on names. Second, poor staffing levels often result in delegation of tasks to overburdened physicians who have never met the patient and have little information about their medical history. Third, obviously staff orientation and briefing on the patient was not done. Fourth, the hospital lacked a procedure to determine competencies of the team involved. Fifth, communication barriers affected communication with patients, families, and care providers prior to the procedure. Sixth, there was total communication failure among specialists involved. Finally, the event displayed limited availability of patient information to specialists.


Ballard, K. A. (2003). Patient Safety: A Shared Responsibility. Online Journal of Issues in Nursing, 8(3), Manuscript 4.

Cerniglia-Lowensen, J. (2015). Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool. Journal of Radiology Nursing, 34(1), 4–7. Web.

Chassin, M. R., & Becher, E. C. (2002). The Wrong Patient. Annals of Internal Medicine, 136(11), 826-833. Web.

Sadigh, G., Loehfelm, T., Applegate, K. E., & Tridandapani, S. (2015). Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. American Journal of Roentgenology, 205(2), 337-43. Web.

The Joint Commission. (2013). Comprehensive Accreditation Manual for Hospitals: Sentinel Events. Web.

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1. NursingBird. "Sentinel Event: Surgical Procedure on the Wrong Patient." April 30, 2022.


NursingBird. "Sentinel Event: Surgical Procedure on the Wrong Patient." April 30, 2022.