Sentinel Event: Surgical Procedure on the Wrong Patient

It is noted that wrong patient errors are still common (Sadigh, Loehfelm, Applegate, & Tridandapani, 2015).

Owich Combulo (assumed name) was a 40-year-old woman admitted to a facility for cerebral angiography. A day after her intended procedure, the patient was wrongfully taken for an invasive cardiac electrophysiology surgery.

The patient had been well, but a recent accident left her with a head insult. A subsequent magnetic resonance imaging detected large cerebral aneurysms. As such, the radiologist admitted Ms. Combulo for cerebral angiography. All cerebral angiography procedures were done successfully. After the procedures, however, Ms. Combulo was transferred to the wrong oncology unit instead of her initial bed at the telemetry unit.

The patient was ready for discharge in two days. The next day, however, Ms. Combulo was taken for a cardiac electrophysiology surgery. After about one hour into the invasive procedure, it was determined that she was the wrong patient for the procedure. The procedure was halted and the patient was returned to her ward in a good condition. Ms. Combulo shared her last name with the correct patient for the invasive cardiac electrophysiology surgery.

The barriers to communication identified in the event

The most vital latent conditions – system faults observed were communication failures, teamwork and identification challenges. This sentinel event displayed poor communication, which is particularly common in large hospitals. Physicians did not effectively communicate with the nurses. Attending specialists did not communicate with resident physicians while other care providers from the telemetry unit and oncology unit failed to communicate. In addition, not all care providers listened to the patient while the process of obtaining the informed consent, which could have protected the patient, appeared to be fundamentally flawed.

Hence, communication barriers played a critical role in this sentinel event – an invasive surgical procedure on the wrong patient (Chassin & Becher, 2002).

The nurse administrator’s role in the event and an appropriate analysis of correcting errors to improve outcome

The case depicts a case for immediate and total disclosure of the wrong patient error. The nurse administrator must ensure full honesty, disclosure and inform the patient and families. The nurse administrator is responsible for patient safety and must systematically evaluate the complex dynamics that influence safe delivery of care services (Ballard, 2003).

When the nurse administrator assesses the system to safeguard against wrong patient surgery, they need to ask critical questions to determine the problem with the hospital procedures and policies. In addition, they must assess the system effectiveness on managing built-in redundancies and measures for practitioners to review patient information effectively.

The nurse administrator should determine the right orientation and training processes and ensure that the right care providers participate to meet universal standards.

The nurse administrator must recognize the role of the team and insist on a team approach to develop solutions, particularly on enhancing verification of patient identities.

A risk analysis and/or root cause analysis

According to the Joint Commission, a root cause analysis for wrong patient invasive procedure should include the following elements (The Joint Commission, 2013; Cerniglia-Lowensen, 2015).

First, the individual identification process for the patient was not executed. As such, a wrong patient was sent for a wrong procedure. The hospital should develop unique patient identification processes and procedures rather than relying on names. Second, poor staffing levels often result in delegation of tasks to overburdened physicians who have never met the patient and have little information about their medical history. Third, obviously staff orientation and briefing on the patient was not done. Fourth, the hospital lacked a procedure to determine competencies of the team involved. Fifth, communication barriers affected communication with patients, families, and care providers prior to the procedure. Sixth, there was total communication failure among specialists involved. Finally, the event displayed limited availability of patient information to specialists.


Ballard, K. A. (2003). Patient Safety: A Shared Responsibility. Online Journal of Issues in Nursing, 8(3), Manuscript 4.

Cerniglia-Lowensen, J. (2015). Journal of Radiology Nursing, 34(1), 4–7. Web.

Chassin, M. R., & Becher, E. C. (2002). The Wrong Patient. Annals of Internal Medicine, 136(11), 826-833. Web.

Sadigh, G., Loehfelm, T., Applegate, K. E., & Tridandapani, S. (2015). Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. American Journal of Roentgenology, 205(2), 337-43. Web.

The Joint Commission. (2013). Comprehensive Accreditation Manual for Hospitals: Sentinel Events. Web.

Calculate the price
Make an order in advance and get the best price
Pages (550 words)
*Price with a welcome 15% discount applied.
Pro tip: If you want to save more money and pay the lowest price, you need to set a more extended deadline.
We know how difficult it is to be a student these days. That's why our prices are one of the most affordable on the market, and there are no hidden fees.

Instead, we offer bonuses, discounts, and free services to make your experience outstanding.
How it works
Receive a 100% original paper that will pass Turnitin from a top essay writing service
step 1
Upload your instructions
Fill out the order form and provide paper details. You can even attach screenshots or add additional instructions later. If something is not clear or missing, the writer will contact you for clarification.
Pro service tips
How to get the most out of your experience with Online Academic Experts
One writer throughout the entire course
If you like the writer, you can hire them again. Just copy & paste their ID on the order form ("Preferred Writer's ID" field). This way, your vocabulary will be uniform, and the writer will be aware of your needs.
The same paper from different writers
You can order essay or any other work from two different writers to choose the best one or give another version to a friend. This can be done through the add-on "Same paper from another writer."
Copy of sources used by the writer
Our college essay writers work with ScienceDirect and other databases. They can send you articles or materials used in PDF or through screenshots. Just tick the "Copy of sources" field on the order form.
See why 20k+ students have chosen us as their sole writing assistance provider
Check out the latest reviews and opinions submitted by real customers worldwide and make an informed decision.
Thank you!
Customer 452545, February 6th, 2021
Thank you!
Customer 453145, April 19th, 2022
For some reason I did not get an email that the order was done, but it was on time regardless
Customer 453291, October 16th, 2022
Business Studies
Thank you very much for a good job done and a quick turn around time.
Customer 452615, March 31st, 2021
Social Work and Human Services
Great work I would love to continue working with this writer thought out the 11 week course.
Customer 452667, May 30th, 2021
Business Studies
Thank you so much! I had to take my dog to the ER and had no time for the assignment. I really appreciate your help! I can't thank you enough! I really appreciate the work and integrity put into it. Thank you for taking it seriously and not bullshiting the paper.
Customer 452815, July 26th, 2021
Great paper, Thank you so much.
Customer 453209, October 4th, 2022
Business Studies
First of all, the writer made sure that he completely understood my assignment and all the guidelines before he began writing. My paper was finished very fast and well before the specified deadline. I thought it was written excellently. He definitely completely grasped the topic. Overall, he is a great writer and I couldn't have asked for better.
Customer 452441, November 29th, 2021
English 101
IThank you
Customer 452631, April 6th, 2021
Looks great and appreciate the help.
Customer 452675, April 26th, 2021
Business and administrative studies
Customer 453201, November 21st, 2022
IT, Web
Awesome paper in such a short amount of time. Was in a jam with another service who didn't deliver, but Theresa did the job correctly. I will use her again to do my essays for sure!
Customer 452967, November 27th, 2021
Customer reviews in total
Current satisfaction rate
3 pages
Average paper length
Customers referred by a friend
15% OFF your first order
Use a coupon FIRST15 and enjoy expert help with any task at the most affordable price.
Claim my 15% OFF Order in Chat
Live ChatWhatsApp