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August 2021

A recent report out of Ohio’s University Hospitals in Cleveland was that they

made a mistake in transplanting a kidney into the wrong patient.  Those of us

in the patient safety field are probably not surprised.  What is surprising is that

the hospital leadership took full responsibility, admitted the error and


I rarely comment on specific cases because

there are so many sides to them.  This story

is no different.  What I do want to ask is this:

was there any chance that a conversation

with any of the patients involved (or left out)

could have changed this outcome?  Articles

related to this mishap are being written

about what the hospital staff should have done and how this could have been

prevented and what changes will be made. Nowhere is there a suggestion of

what the patient or their family could have done to stop the error from

reaching the patient.

The “Swiss Cheese Model” describes how errors slip through safety protocols

and reach patients. Imagine random slabs of Swiss cheese in a stack. Each

slice is like a layer of safety precautions. Usually, the holes don’t all line up and

a skewer you try to poke through will hit a wall. But occasionally, all the holes

in the Swiss Cheese line up.  At any time, medical staff can block the hole and

keep the error from reaching the patient. Errors can be caused by

miscommunication, staff shortages or errors in judgment, but rarely by bad

people or bad care. There is no model that explains (and teaches the public)

that patients and advocates can be another layer to block up the holes and

protect themselves. 

Too often patients believe that the hospital staff know best and patients who

may be weary, feeling vulnerable and even intimidated, believe that they

themselves must be mistaken. It’s not easy to speak up while lying in bed,

almost naked, hoping that the same person who forgot to wash their hands

this morning will get you a bedpan in time.

Patients are often at the mercy of the healthcare team, so learning to be

outspoken and assertive but respectful comes with practice. Hospital

leadership often believe that their staff always follow policies such as washing

their hands before touching a patient. but as an advocate often at the

patient’s bedside, I can tell you that sometimes they don’t.  The policy may be

to wash but the lack of hand-washing doesn’t happen in the boardroom where

policy is made.

Until people are taught to become well-prepared patients and we are all

speaking up for ourselves and our family members, we can keep expecting

these medical errors to continue.


Ilene Corina is a Board-Certified Patient Advocate and President of Pulse

Center for Patient Safety Education & Advocacy.  She is a part of the

Leadership Council of TakeCHARGE Campaign: 5 Steps to Safer Health Care

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