The management of medical records was brought under review at Letterkenny University Hospital last year after a doctor discussed a wrong patient’s medical history.
The confusion arose when a woman was at the hospital preparing for a surgical procedure. A doctor began discussing her medical history with her but she realised it was not hers.
She then discovered a letter on her file belonging to a different patient but with the same name as hers.
The woman cancelled the procedure and complained to the hospital. Details of the case, published in the 2019 Ombudsman’s report today, said that the woman was unhappy with how the hospital responded to her complaint.
The Ombudsman Peter Tyndall determined that the doctor had quoted the wrong medical history as he had read it from another patient’s record, which was misfiled on the woman’s medical chart.
It also emerged that a ‘General Incident’ form had not been completed immediately after the incident. It was completed after the woman had complained to the hospital, and details on the form were not entirely accurate.
Following the incident, the General Manager of LUH apologised to the woman for the distress she had suffered. Refresher training was given to hospital staff on the correct filing of documents in medical record charts.
The hospital also reviewed its policies and delivered extra training to staff to avoid a similar incident occurring.
The Ombudsman will be following up with the hospital in mid-2020.