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Publication Type: Safety Learning Summary
Single or Multiple Incident: single
Date: 2/1/2010 12:00:00 AM
Country: Canada
"An elderly patient in a community hospital, at risk for falls, was found lying on the floor on the left side. An x-ray order was written and a Diagnostic Imaging (DI) Consultation Form completed in follow up to the patient's complaint of left shoulder pain. The DI Staff interpreted the order to read right shoulder x-ray and the x-ray report indicated there were no injuries. Approximately one week later, shoulder bruising led the attending physician to order a second x-ray of the left shoulder. The same DI Staff received the written consult form and questioned the exam site as the handwriting resembled a capital R and a miniscule t. Unit Staff clarified that the left shoulder was the site to be x-rayed. The x-ray confirmed a fracture of the left distal clavicle, orthopedics was consulted, and a sling recommended. Until the second requisition was received by DI Staff, no one had noticed that the wrong should had been x-rayed. There were multiple staff members caring for the patient during this time period. There is no defined standard practice for unit staff and physicians to review, sign and file DI results. There is no process in place to ensure that a DI consult is cross-checked with the patient's original complaint and physician order. "


Rules / Policies / Procedures
  1. Develop a site process to verify hand-written requisitions.
  2. Review and formalize the current site processes for crosschecking and comparing patient's complaint with the DI results.

Wrong site x-rayed following misinterpretation of requisition