Melissa Kain, a 21-year-old aerobics instructor, made a rare visit to her primary physician, Dr. Summer,
who was affiliated with Curative Health. Melissa saw Dr. Summer that day to discuss persistent heartburn,
which had progressively worsened despite taking Prilosec OTC for the last month. Dr. Summer examined
Melissa, discussed her symptoms and decided she needed an esophageal motility study and a 24-hour
esophageal pH study to be performed in the Curative Health GI lab. Dr. Summer wrote an order for the
tests, completed the appropriate forms and signed his name.
On that same day, Mary Kainer, a 52-year-old bus driver, was seen at the Internal Medicine clinic at
Curative Health for her yearly physical with Dr. Kim. She reported some arthritis problems in her right
knee and a little “stomach trouble” after eating Mexican food. Dr. Kim ordered routine blood work and
asked Mary to schedule her annual mammogram at her convenience. Mary thanked her and left.
Late that afternoon, Dr.Summer’s nurse called Curative Health’s centralized scheduling service to schedule
Melissa Kain’s tests. Here’s how the call went:
Nurse: “Hello. This is Jane from Dr. Summer’s office. I need to schedule an esophageal motility study
and a 24-hour esophageal pH study for Melissa Kain.”
Scheduler: “OK. Let me pull that up on the computer. Now make sure I have those tests right … an
esophageal motility study and a 24-hour esophageal pH study. Right?”
Nurse: “Yes, that’s right for Miss Kain, Dr. Summer’s patient.”
Scheduler: “We’ve got a slot at 2:30 on January 5. I’ve got that scheduled. Thanks.” The call ended.
While she was on the phone, Curative’s centralized scheduler was looking at the online scheduling system
called IDX. After working 20 years in admissions, she had just transferred to the centralized scheduling
center, but was well experienced with scheduling patients into IDX. When the scheduler heard the
patient’s name, she entered the last name into the computer and found the patient. She completed making
the appointment and filled out a form called the Diagnostic Center Patient Information that would be sent to
the GI clinic. This “pink sheet” contains patient demographics, primary physician name, referring
physician name, insurance information, and exam information. She then faxed the sheet to the GI lab,
scheduling the GI tests on January 5 for Mary Kainer.
In order to prepare the patients for their procedures, the GI nurses call all patients the day before the
procedure to give instructions about any preparation they need and to remind patients of their appointment
times. On January 4, a GI nurse called Mary Kainer’s house to speak with her about her GI tests that would
be performed the following day. Mary was on her afternoon bus route so she did not receive the call. The
GI nurse left the following message on Mary’s answering machine:
“Your primary care physician has scheduled you to have an esophageal motility study and a 24-hour
esophageal pH study at 2:30 p.m. tomorrow with Dr. Magee at the GI lab. Please arrive at the lab 15
minutes early and bring your insurance card. The GI lab is located in the Physicians Office Park on
Rangeline. Thank you.”
Although Mary wasn’t expecting the call and knew nothing about a GI appointment, she assumed that Dr.
Kim wanted a specialist to check on her stomach troubles so she arrived promptly at the GI clinic at 2:30
p.m. on January 5. She checked in with the receptionist who “arrived” Mary at the clinic into the IDX
system. The receptionist pulled Mary’s pink sheet, notified the nurses that she was here and asked Mary to
have a seat in the waiting room.
The GI lab was running on time that day; the nurse called out “Mary Kainer,” and Mary was quickly taken
back to the procedure room. The GI lab does not routinely gain informed consent for a motility study
because the risks from the procedure are very low; most patients just experience some minor discomfort.
The GI nurse slipped an esophageal pressure tube through Mary’s nose into her esophagus and was just
completing the test as Dr. Magee entered the room. When he mentioned that he would be sending results
of this test to Dr. Summer, she responded, “I’m not sure what doctor you’re talking about. My family
doctor is Dr. Kim.”
At that point, Dr. Magee asked to see the original order from Dr. Summer’s office. Sure enough, the order
from Dr. Summer was for Melissa Kain. Dr. Magee immediately informed Mary of the mistake,
apologized and told her his office would get to the bottom of the incident and make sure it didn’t happen
again. Mary was not upset and asked Dr. Magee about her “stomach troubles.” Dr. Magee told Mary her
esophageal motility study was completely normal. The second test was not performed, and Mary was not
charged for the first study.
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Case Flow Diagram
Melissa Kain visits her
family physician for
persistent heartburn.
Mary Kainer has yearly
physical with Dr. Kim.
Dr. Summer examines
Melissa and decides that
both an esophageal
motility study and a 24hour esophageal pH study
need to be done.
Dr. Kim orders routine
blood work and reminds
Mary to schedule her annual
mammogram.
GI nurse calls Mary Kainer
to confirm GI test but only
leaves a message.
Dr. Summer writes the
order for the test and fills
out the forms.
Dr. Summer’s nurse calls
the GI lab to schedule
Melissa Kain’s tests but
was told to call the new
centralized scheduling
service.
Scheduler enters last name,
makes appointment and
faxes pink sheet for Mary
Kainer to the GI lab
Mary Kainer, somewhat
confused about the test but
trusting her physician,
arrives at the GI clinic and
checks in.
Mary is taken to the
procedure room and the
nurse slips an esophageal
pressure tube through her
nostril into her esophagus.
Nurse calls centralized
service to schedule tests for
Melissa Kain.
Dr. Magee, the GI doctor,
mentions to Mary that Dr.
Summer was concerned and
ordered the test.
Mary mentions that her
family doctor is Dr. Kim, not
Dr. Summer.
Dr. Magee informs Mary of
the mistake and apologizes,
assuring her that they would
investigate the problem.
Dr. Magee becomes
suspicious and checks the
original order and finds that
the order from Dr. Summer
was for Melissa Kain.
2
Case Contributing Factors:
Equipment (design, availability and maintenance)
There were no alerts built into IDX computer system for duplicative or sound alike names or no
forcing function to verify all demographic information before scheduling.
Environment (staffing levels and skills, workload and shift patterns, administrative and managerial
support, physical plant)
Were there too many calls or scheduling tasks at once?
Teamwork (verbal and written communication, supervision and assistance)
Was communication between front line team members (scheduler and nurse) adequate? No.
Staff (knowledge and skills/training, competence, physical and mental health)
Team may blame the scheduler for not picking the right patient (misunderstanding sound alike
names and not verifying the correct patient). James Reason: Humans are fallible and errors are
to be expected. “Leaving out necessary task steps is the single most common human error type.”
How many times have you left the last page of your original in the photo copier?
Scheduler performed task at least 50 times a day … wasn’t lack of experience or training.
Sometimes humans omit necessary steps from common tasks.
Reason’s work on approaches to human error – viewed either as person approach or system
approach. In person approach, errors are the fault of a human who should have acted differently
(labeled careless, poorly motivated, negligent, forgetful). In a systems approach, errors are seen
as consequences of upstream system factors including recurrent “error traps” in workplace.
Institutional Context (economic and regulatory situation, availability and use of protocols,
availability and accuracy of tests)
Were there methods for monitoring adequacy of staff communication in place at this institution?
No.
There were no expectations for “read backs” between workers, or confirmation messages or
debriefs. There were no “scripts” or “checklists” developed for scheduler to confirm information
with other party.
The consent paper became more important than the consent process.
Organization/Management (financial resources and constraints, organizational structure,
policy standards and goals, safety culture and priorities)
1. GI nurse leaving message on answering machine.
Might blame the nurse for not directly speaking to patient instead of leaving a message.
Was it a workplace norm for GI lab to leave messages on machines? Probably. Also, it was
procedure to call the day before necessitating leaving the message on machine, not waiting for
patient to call back.
2. Process for scheduling patients did not include scheduling test from ORIGINAL order and also
did not include a comparison of written ORIGINAL order with “pink sheet” sent from schedulers.
3. Process of clinic verification of patient included only patient agreement with demographic
information. In this case didn’t catch wrong patient. Needed referring physician name.
Standardized approach was missing. Left to individual receptionist, nurse, etc. to determine how
to verify patient. Most used name only.
4. Process for consenting the patient. Verifying basic information BEFORE test performed.
Patient (complexity and seriousness of condition, language and communication,
personality and social factors)
May blame the patient. Why didn’t patient question the unknown test? Trust of health care
system and personal physician. Patient get comfortable with physician’s not communicating what
the treatment plans are. Cultural norm. Age differences.
3
What can be done to keep it from happening again?
Standardize/Simplify/Make Protocol
Automation/Computerize
Education/Training
Improve or Change Devices/Equipment
Communication
Other (Describe)
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