Wrong patient

A husband called their practice to request a home visit for his wife who had decided to be at home during her final days. The GPST who was triaging home visits that day misread the receptionist’s note and accidentally pulled up the records for another patient with a similar surname. When he called to make the visit, he was surprised to find no one at home.

The patient’s husband complained to the practice that he had eventually needed to call the out-of-hours service to provide symptom control for the patient in the final hours before her death.

The practice reviewed the records for all the patients triaged that day to see how the mix-up had occurred. It emerged that the GPST, who had recently joined, had not been aware of the practice’s protocol in which GPs called to confirm the address with the patient/carer when arranging a home visit.

In its response to the complaint, the practice apologised to the patient’s husband. The letter explained what had gone wrong and the steps it had taken to tighten its procedures. The husband was satisfied that lessons had been learned and did not take matters further.

MDU advice

• When you start a new placement, ensure the practice provides a suitable induction which should usually include running through key policies and procedures, computer systems, who to contact for help and the handover/referral of patients.
• If you are made aware of a complaint then you must cooperate with any formal inquiry or complaints procedure. This is likely to require a statement of your involvement in the incident and you may find it easier and reassuring to contact the MDU’s medico-legal advisers for advice at the outset.
• Try to take something positive from mistakes. Your reflections on what went wrong, why and how you will do things differently next time are a useful addition to your ePortfolio.

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