A Medical Error

A recent report out of Ohio’s University Hospitals in Cleveland was that they made a mistake in transplanting a kidney into the wrong patient.  Those of us in the patient safety field are probably not surprised.  What is surprising is that the hospital leadership took full responsibility, admitted the error and apologized.

I rarely comment on specific cases because there are so many sides to them.  This story is no different.  What I do want to ask is this: was there any chance that a conversation with any of the patients involved (or left out) could have changed this outcome?  Articles related to this mishap are being written about what the hospital staff should have done and how this could have been prevented and what changes will be made. Nowhere is there a suggestion of what the patient or their family could have done to stop the error from reaching the patient.

The “Swiss Cheese Model” describes how errors slip through safety protocols and reach patients. Imagine random slabs of Swiss cheese in a stack. Each slice is like a layer of safety precautions. Usually, the holes don’t all line up and a skewer you try to poke through will hit a wall. But occasionally, all the holes in the Swiss Cheese line up.  At any time, medical staff can block the hole and keep the error from reaching the patient. Errors can be caused by miscommunication, staff shortages or errors in judgment, but rarely by bad people or bad care. There is no model that explains (and teaches the public) that patients and advocates can be another layer to block up the holes and protect themselves. 

Too often patients believe that the hospital staff know best and patients who may be weary, feeling vulnerable and even intimidated, believe that they themselves must be mistaken. It’s not easy to speak up while lying in bed, almost naked, hoping that the same person who forgot to wash their hands this morning will get you a bedpan in time.

Patients are often at the mercy of the healthcare team, so learning to be outspoken and assertive but respectful comes with practice. Hospital leadership often believe that their staff always follow policies such as washing their hands before touching a patient. but as an advocate often at the patient’s bedside, I can tell you that sometimes they don’t.  The policy may be to wash but the lack of handwashing doesn’t happen in the boardroom where policy is made.

Until people are taught to become well-prepared patients and we are all speaking up for ourselves and our family members, we can keep expecting these medical errors to continue.


Ilene Corina is a Board-Certified Patient Advocate and President of Pulse Center for Patient Safety Education & Advocacy.  She is a part of the Leadership Council of TakeCHARGE Campaign: 5 Steps to Safer Health Care


[email protected]


Posted in

Pulse Center for Patient Safety Education Advocacy