An 85-year-old woman presented to the facility in a disoriented state following a reported tumble. Her left hip was sore, and X-rays revealed a nondisplaced femoral neck fracture, meaning the break below the hip joint’s ball had not shifted position.
The orthopedic surgeons performed an assessment. Considering her age, pre-existing conditions, and their description of minimal pain and tenderness, they decided to treat the break without surgery. Their note was optimistic: “We’re reassured to see the patient is able to weight-bear without pain.”
The following day, a medical intern reviewed that documentation and paused. The patient was immobilized on strict bed rest and experiencing significant pain. She had not taken a single step.
The orthopedic staff had actually examined the wrong woman. They had assessed her hospital roommate, another senior citizen who spoke Cantonese.
A Misdiagnosis That Influenced the Care Plan
The incident, “Mistaken Identity,” was documented in 2008 by PSNet, which is the safety network of the federal Agency for Healthcare Research and Quality.
This scenario is noteworthy because the error did more than generate an odd chart entry; it directly influenced a treatment decision.
The surgeons’ advice against an operation relied on the assumption that the patient had little pain and could bear weight. When the mistake was discovered, the orthopedic team apologized and offered surgical repair to the correct individual.
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The intern detected the discrepancy because the note contradicted the patient’s actual condition. Had she not reviewed the file, her treatment might have been based on an examination of a different person.
In his commentary, Leslie W. Hall, then senior associate dean for clinical affairs at the University of Missouri-Columbia School of Medicine, argued that correctly identifying a patient seems straightforward, yet many variables can cause it to fail.
Similar Demographics and a Shared Language
Multiple risk factors converged. The patient’s confusion hindered her ability to verify her identity. She and her roommate shared similar ages and spoke the same language, which likely facilitated the team’s assumption that they were dealing with the right patient.
Hall identified limited English proficiency and shared names as recurring causes of identification mistakes.
Lack of language skills correlates with more severe harm. Joint Commission researchers analyzed 1,083 adverse event reports from six U.S. hospitals in 2005. According to their pilot study, 49.1% of events involving patients with limited English resulted in physical harm, compared with 29.5% for those fluent in English. The injuries were also generally more severe.
Of the harmful events, 46.8% of those involving patients with limited English ranged from moderate temporary harm to death, whereas the figure was 24.4% for English speakers. Errors involving patients with limited English were also more likely to be caused by communication issues, at 52.4% versus 35.9%.
Hall’s data highlights the prevalence of wrong-patient errors. He referenced 27 invasive procedures performed on the wrong patients in New York from 1998 to 2001 and 63 wrong-patient surgical procedures reported in Florida from 1990 to 2003. He noted that reporting systems typically undercount, so the actual numbers are likely greater.
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He also cited statistics showing that approximately 0.1% of blood transfusions involve an error, with the recipient being misidentified as the cause in about two-thirds of cases. In some large health systems, up to half of patients share a name with at least one other individual. In one neonatal intensive care unit, patients with identical surnames were present on 34% of patient days. Hall also pointed out that wristbands can fail: he cited 236 incidents and near misses in the United Kingdom related to missing or incorrect wristbands within less than two years.
Roommate Mix-Ups Still Make Headlines
Confusion between individuals sharing a room or home has led to severe consequences. In 2021, staff at PeaceHealth Southwest Medical Center in Vancouver, Washington, mistakenly identified a patient named David Wells as his roommate, Michael Beehler, after Wells was admitted following a choking incident, as reported by Becker’s Hospital Review.
Beehler’s sister was asked to make end-of-life decisions for a man she thought was her brother, and she consented to the withdrawal of life support. Beehler was still alive. In December 2024, Wells’ son, Beehler, and Beehler’s sister filed a lawsuit against the hospital, alleging negligence and emotional distress. The claims have not been verified in court.
Two Identifiers and an Interpreter
Hall noted that verifying the wristband is widely considered the primary safeguard. He also advised for active identification, requiring patients to state their name and provide a second identifier, such as a date of birth.
The Joint Commission’s 2026 National Performance Goals mandate that hospitals use at least two patient identifiers and forbid using a room number or location as one. The case of the two women in the same room illustrates the necessity of this rule.
For patients with limited English, Hall advised using professional interpreter services, confirming comprehension, and flagging these patients with alerts or wristband markings. He also suggested including photos on wristbands.
Families can also play a role. Relatives of older or confused patients, particularly those who do not speak English, can ask clinicians to confirm the patient’s name and birth date at the bedside and request an interpreter.
