My Health Discovery

Patient Care: A Comma Could Save Your Life


A little mistake can pose a big threat to safety in a healthcare setting. Here’s a personal account of why self advocacy is so important in patient care.

10:45 a.m.  “He’s waking up, but still groggy,” Rose told us. My father’s partner had just taken a call from the nurse assisting in his surgery. An ICD implant – Implantable cardioverter-defibrillator. It will pace his heart and automatically correct fast heart rhythms should his infarcted left ventricle go into ventricular tachycardia causing a cardiac arrest. “We can go back and see him at noon,” Rose said.

12:00 noon.  “Family of Rosario,” the station nurse called out. Rose, my sister Laura, and I hurried up to the counter where the nurse pointed to the phones. “Over there, they want to talk to you.”

Apprehensive, I picked up the handset laying off the hook. “Hello?”

“Who am I speaking with?”

“This is Rosario’s daughter, Dina.”

“Okay. We found a blockage. We have to go back in with a balloon and place a stent.”

I asked a couple questions, thanked the nurse and returned the handset to its cradle. Relaying the message to Rose and Laura, I felt a bit confused. “How could they fish wires into his heart and not know there was a blockage first?”

I called my brother Phillip, a paramedic who was on duty that day. He spit out medical questions too complicated for me to answer. We went downstairs to put things in the car and grab a bite to eat, but 15 minutes later Rose answered a call on her cell phone from another nurse. “We’ve been trying to find you. You can go back and see him now.”

Bewildered, Rose relayed the information we had just received. “That sounds fishy,” she replied. “Let me look into it. Come back upstairs.”

“You don’t tell a patient’s family members something sounds ‘fishy’!” I exclaimed as we scurried back to the elevators.

Back upstairs they took us in to see Dad, who was sitting up and smiling. The nurse confessed we received an erroneous update on another patient whose last name was Rosario. My father’s implantation went perfect and he did not have an angiogram or stent placed. After drilling me with questions, the nurse left to investigate how the miscommunication occurred. I phoned Phillip again to ease his mind that Dad was awake. He reacted with a few expletives, but I assured him the charge nurse was on the case and Dad was okay.

Soon after, the charge nurse returned. She reported that there was another patient in the cardiac unit at the same time whose last name was Rosario. My father remembered before they took him back to surgery that a medical student addressed him as Mr. Rosario and he had corrected her. The comma was missing from her form where it read last name then first name. We shuddered at the thought of what could have happened if the cardiac nurse had mixed up the names in the same way before bringing each patient back to the operating rooms.

The difference between an angioplasty and ICD implant came down to a comma.

An honest mistake, right? The charge nurse was not as relieved. She indicated this would be a topic at their next staff meeting. “We can’t get it right just 98% of the time, it has to be 100%,” she expounded. “Accurate patient care is our chief priority!”

The reminder here is to ask questions, always! If you’re the patient or the family member, ask. Ask again. Ask other staff. Yes, they’re miracle workers, but they’re also human; they’re overworked too. The account above is an example of why healthcare consumerism is so important these days. You deserve to be put at ease with whatever procedure, operation or treatment you receive. If your doctors ever make you feel rushed during consultation, stop them and ask them to listen… to hear you. My sister Laura gives a case-in-point:

“Finally being seen by a rheumatologist nearly an hour and a half after my appointment time, her first words were to prescribe medication for a condition that wasn’t quite what was previously explained. As she rushed her answers, inching toward the door, I finally spoke up and asserted that I needed her attention. She continued to rush me, leaving me angry and more lost than ever about my chronic pain. Surprisingly, two hours later she phoned to apologize and asked if I had any other questions.”

I had a similar experience with a specialist who barely looked at me, just down at my chart. Sometimes we all need to be reminded to slow down.

Part of the U.S. Department of Health & Human Services, the Agency for Healthcare Research and Quality offers guidance on patient involvement. No question or clarification asked is trivial when it comes to your health, especially with risky procedures and dangerous medications or drug interactions. Get Questions to Ask Your Doctor Here.

Healthgrades is a popular site for physician details and ratings by patients. It’s helpful in selecting a new doctor or joining the conversation from your own experiences. They even publish an annual report on hospital quality, which also recognizes outstanding clinical outcomes and specialties. View the 2019 Report to the Nation here.

And as for my Dad, Rosario? After he hassled the nurses to let him go home early or serve him a steak, he was released after a few hours and reluctantly stayed home from work for two days to rest. He is still getting used to new restrictions, but we’re proud to say he has been smoke-free six months now. And he’s always sure to use a comma when writing last name, first name!

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