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Based on interviews, medical record review and review of hospital policies and procedures, it was determined that the hospital did not ensure test results for one patient was removed from another patient' s medical record who shared an identical name. Specifically, an echocardiogram was completed on a patient under the wrong medical record number and information regarding tests results remained in the wrong medical record. Identifiers: 1 and 2

Findings include:

1. The survey team requested to review a log of patients who had received echocardiograms during the month of November in an outpatient clinic setting which operated under the hospital' s provider number. The hospital stated they had several cardiology clinics that provided echocardiogram tests, for example a hospital based cardiology clinic, 2 off-campus clinics, a mobile echocardiogram and 8 echocardiogram machines. The hospital stated that each clinic keeps their own logs and it would take time to determine if the clinics kept the logs and if they did, it would be thousands of names. The risk manager stated she had a complaint letter that had an issue with billing errors from the cardiac clinic. The risk manager showed the surveyors a copy of a letter, dated January 2010, and the letter provided was from the patient 1. The surveyors asked to review the medical records of the patient 1 and patient 2.

2. Patient's 1 and 2 were noted to share the same name, same birthday month, and both had a procedure done in the month of November.

3. Review of patient 2's medical record revealed a faxed physician's order, dated 11/23/2009, which included demographics and insurance information for that patient. The medical record also included a clinic note as read by a cardiologist for an echocardiogram dated 1/7/2010. The echocardiogram according to an interview with the risk and cardiology manager was performed in another state by way of a mobile echocardiogram serviced by the hospital.

4. Review of patient 1's medical record revealed a clinic note, dated 11/5/2009, for a dermatology visit and a clinic note for an echocardiogram performed, on 11/24/2009, noted to be almost identical to patient 2's echocardiogram results, dated 1/7/2010, with the interpretation done by the same physician who interpreted the results for patient 2.

5. An interview with the hospital's risk manager and cardiology clinic manager was conducted, on 2/23/2010. When asked how patient 2's information was placed into patient 1's medical record it was revealed that:

a) A physician's order for an echocardiogram for patient 2 was written and faxed to the hospital-based cardiology clinic.

b) The cardiac technician obtained the faxed physician order for patient 2 and took it with him for the mobile echocardiogram. The technician then traveled to a different state, where patient 2 resided, to perform the procedure.

c) The cardiac technician had electronically (from the hospital ' s Master Patient Index [MPI]) pulled-up the patient's name, listed on the faxed order, to see if the patient had ever been treated in the hospital or clinic in the past.

d) The patient whose name was pulled-up on the electronic medical record was patient 1 (who shared the same name with patient 2). The cardiac technician obtained patient 1's Medical Record Number (MRN) from the electronic medical chart. This MRN was used to enter information about the procedure in patient 1's medical record.

e) The faxed physician's order, demographic information, and insurance information was used as the identifier to identify the correct patient (this was appropriate according to hospital policy), however, the faxed order was not verified with the electronic patient record and MRN.

f) According to the cardiology clinic manager the cardiologist unknowingly used patient 1's MRN (obtained earlier by the cardiac technician) to electronically pull-up the patient's medical record where he then documented the procedure. Patient 2's procedure was electronically documented into patient 1's medical record.

g) Patient 1's insurance was not involved in the mix-up since patient 2's demographics and insurance information were in paper form and used to identify the correct patient; it was the procedure that was electronically entered into the wrong patient's medical record.

6. Review of the hospital's policy and procedure for patient identification revealed that patient care identification for an outpatient or clinic visit was to:

a) Ask the patient to state their full name and date of birth.

b) Verify information with order.

c) If the patient is unable to verbally state their name and date of birth ask to see identification.

7. Hospital customer service was made aware of the patient mix-up in January 2010 when patient 1 sent in a letter after receiving a bill for a procedure that he had not had. Customer service e-mailed the medical records department, letting them know that patient 1's medical record contained information about patient 2. An interview conducted, on 2/23/2010, with the medical records staff revealed that the visit number that was placed in patient 1's medical record was removed and placed in patient 2's medical record. The medical records staff were asked why the procedure that was performed, on 11/24/2009, on patient 2, was still in the medical record of patient 1. The medical records staff stated that because it was electronic charting, by hospital policy, only the physician could delete the information and the physician had not yet done so. The medical records staff were asked if they verified that the physician has changed or removed wrong information from patient 1's medical record. The medical records staff stated that they do not.

8. When asked why there was a clinic note for an echocardiogram in patient 2's medical record, dated 1/7/2010, when the procedure was performed, on 11/24/2010. The cardiology clinic manager stated that when the mix-up was discovered, the cardiologist, by hospital policy, was required to reread the report. The physician dated it the day it was reread and not the day it was performed. The report was then placed electronically in the correct patient's chart (patient 2).

9. A medical records employee and the risk manager were asked if patient 1 were to request a copy of his medical record, would patient 1 receive the complete medical record, including patient 2's echocardiogram, performed on 11/24/2009. The medical records employee and the risk manager stated, until the physician deleted patient 2's echocardiogram information, it would remain in the medical record for patient 1.