Two Pregnant Women With the Same Name

During my daughter’s difficult delivery I was shocked at the paper system of medical records used by an otherwise modern hospital. After my wife and I arrived in the Labor, Delivery, and Recovery unit, the on-call obstetric resident took more than 30 minutes and two trips to find my wife’s medical records. The delay was partially due to my wife sharing the same first and last name with another patient served by the same OB/GYN practice.

On three previous visits to the OB/GYN a staff member (two medical assistants and one medical student) had grabbed the wrong patient folder and brought it into my wife’s appointment. Following the first incident, the doctor scribbled “Name Alert” with a black pen onto the front cover of the dark red manila folder. Needless to say, this procedure was not effective. Despite the written “Name Alert” on the folder, we encountered the same name problem two more times before the final incident when we arrived at the hospital in labor.

Medical errors due to patients having the same name are common enough to be widely mentioned by both popular press and medical associations. Entire academic articles have been written about managing patients with the same name and government agencies cite the same name issue as a health concern. The problem is not limited to the U.S. as a major British paper writes about patients being given the wrong medication intended for another patient with the same name.

The American Academy of Family Physicians recommends medical offices use a dual-identifier system of name and birth date to minimize errors. Every medical doctor and nurse practitioner at Tufts Medical Center utilized this procedure by asking for name and date of birth as confirmation. However, this process is only as effective if used by even the lowest-paid staff member.

The first time we were exposed to the name issue, our nurse practitioner walked in with a patient folder, greeted us, then immediately walked out to retrieve the correct folder. She returned explaining that the medical assistant had pulled the wrong folder and handed it to her, but that she had immediately noticed the error because she remembered us personally. The second time we encountered the name issue, a medical student brought in the wrong patient folder (clearly not having verified the date of birth) for a preliminary interview and then handed it to the OB/GYN when she entered. Since the OB/GYN had no reason to believe the folder was for the wrong patient, she only noticed the error when she consulted the chart for background on gestation dating.

It would be impossible for individual patients to correct an issue that appears endemic to the entire system. However, it is possible for patients to verify that their own medical providers have the correct patient file prior to treatment. For women who are pregnant, the problem intensifies closer to a due date as it is hard to remember one additional thing to ask about during each appointment. This is one area where the father of the baby or close friend can help immensely. Remembering to ask whether there is another patient with the same name at a medical practice can eliminate concern (if the answer is no) or force the medical provider to enact their form of a name alert system.

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