Learning Note from the notification scheme of events in specialized health services where the wrong patient was treated

This is a short learning memorandum concerning “Wrong patient was treated.” The Health Department has received around 35 messages per month in which the wrong patient was treated because of misunderstandings.

Learning note is specifically aimed at managers of clinical departments and personnel who are responsible for organizing patient flow and patient record systems as well as those performing ID verification. The note is also relevant departments for medical biochemistry, imaging, pathology departments and departments of immunology and transfusion medicine.

This paper is also published on Helsedirektoratets nettsider under Publikasjoner, type Læringsnotat.

Learning notes contains information from § 3-3 to institutions covered by the statutory obligation to report incidents that cause, or could have given considerable damage to the patient. Illuminated risk areas is based on the content of messages.
It is not conducted systematic searches for improvements in connection with the preparation of the note.

The Health Department is considering incidents in a system perspective and direct their attention towards preventing future occurrences.

It is desirable that the note is used as part of improvement work in patient safety in the special Health department.

Dersom det ønskes nærmere informasjon, eller ved tilbakemeldinger på læringsnotatet, vennligst kontakt:

Eli Saastad, researcher, PhD. E-mail: Eli.Saastad@helsedir.no. phone 24 16 35 17
Øystein Flesland, Head of Section, dr.med. E-mail: Oystein.Flesland@helsedir.no. phone 459 69 707

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