A patient receives a D&C meant for another patient, leading to a miscarriage
Key Takeaways
Staff at Bulovka University Hospital in Prague mixed up two patients, giving one of them—a woman who was four months pregnant—a D&C she did not ask for.
The hospital and the staff involved are now under investigation. Reports say that language barriers led to the breakdown in communication.
Experts say that while errors do occur, staff must follow policies and procedures for patient identification, and that clinicians must focus on mindfulness and presence to prevent these tragic mixups.
Medical professionals in the Czech Republic performed a gynecological procedure on the wrong patient, leading her to have a miscarriage, The Independent reported last week.
The mix-up occurred on March 25 at Bulovka University Hospital in Prague, where a patient who was four months pregnant sought a checkup but instead received a dilation and curettage, or D&C, a surgical procedure in which the cervix is dilated so that the endometrium can be scraped with a curette to remove abnormal tissues. The patient subsequently had a miscarriage. Meanwhile, the procedure was meant for another patient.[]
D&Cs are common, invasive, and performed for various reasons. First, the procedure can be used to explore or diagnose infertility, cancer, or other conditions, such as bleeding. It can also be used to remove tissues—after a miscarriage or giving birth, for example. The procedure can also be performed on patients seeking early elective termination of pregnancy.[]
The Independent reports that the mix-up occurred due to a language barrier; the woman did not speak Czech. Reports say that the staff involved—a doctor, gynecologist, nurse, and an anesthesiologist—mixed up the two women’s identities, and that both patients may have been of Asian descent.[]
Reports say that the woman who mistakenly received the D&C “was addressed in the waiting room instead of the other patient, and she nodded in agreement and signed paperwork for the procedure.”[]
The Independent reports that Jan Přáda, a gynecologist and the vice-chairman of the Czech Medical Chamber, told local media, “A Czech-speaking patient would probably actively resist the fact that she is going to undergo a procedure that she does not understand.”[]
The incident is now under investigation, and the staff involved have been suspended. Eva Libigerová, a spokesperson for Bulovka University Hospital, told The Independent, “We have expressed our deep regret and apologies to the patient and her entire family for this unfortunate incident and assured her that we will do everything possible to mitigate the harm caused and also compensate her.”[]
In the Czech Republic, abortion is legal up to 12 weeks of pregnancy. Afterward, it’s only allowed in specific cases.[]
Ken Fulginiti, Esq, of Fulginiti Law, says the incident was nothing short of tragic, but that medical errors simply do happen. Fulginiti says he knows of cases in which cancer diagnoses are missed, wrong legs are amputated, and surgical instruments are left inside a patient’s body. “While, with the significance of the [D&C] procedure, we'd like to believe a proper patient check would occur repeatedly, medical errors come in all shapes and sizes,” he says.
Deborah Hunt, PhD, RN, a professor at the College of Nursing and Public Health at Adelphi University and author of “Fast Facts for Patient Safety in Nursing,” echoes Fulginit’s sentiments.[]
“Unfortunately, these types of mix-ups do happen,” she says, citing a 2016 study published in The BMJ in which it was estimated that more than 250,000 deaths occur each year in the US due to medical errors, making it the third-leading cause of death in the US.[]
She says these errors largely come down to improper patient identification, poorly written policies and procedures, lack of adherence to those policies and procedures, inadequate staffing, and—as was the case in Prague—communication issues.
“Usually, when an error occurs, it is due to the fact that one or more healthcare practitioners did not follow the policies and procedures. Not following the correct policy of using two identifiers to verify patient identity is a major factor,” Dr. Hunt says.
Dr. Hunt goes on to say that specific protocols were developed by the Joint Commission to prevent “Wrong-Site, Wrong-Procedure, and Wrong-Person Surgery” in 2003. These steps include pre-procedure verification, marking the procedure site, and performing a time-out. However, by 2022, wrong-site surgeries made up 6% of the nearly 1,500 incidents investigated by The Joint Commission.[] “All healthcare professionals must be knowledgeable about the statistics related to patient safety. [They] must work together to create a ‘culture of safety’ and become ‘patient safety ambassadors,’ receiving ongoing education and competency assessment on patient safety and quality of care,” Dr. Hunt says.
She says clinicians must focus on mindfulness, being present, and focusing on policy and procedure for positive patient outcomes.