Authorities misidentified medevaced NWT patient for three weeks

A Stanton Territorial Hospital clerk’s mistake meant an unconscious patient travelled from the NWT to Alberta under the wrong name. Through an odd set of events, nobody noticed for weeks.

That includes the patient themselves, who didn’t notice the error once they had regained consciousness. A student nurse eventually realized something was amiss.

The case is outlined in a new report from the NWT’s information and privacy commissioner.

A privacy breach took place because, in getting the patient’s identity wrong, the clerk inadvertently entered the case into another person’s medical records. As a result, healthcare workers treated the patient using someone else’s medical records for 21 days.

Using the wrong set of records could also introduce significant medical risk, on top of the privacy concern.

Acknowledging that a breach clearly occurred, privacy commissioner Andrew Fox concluded the health authority had responded appropriately once the issue became apparent.

Alongside recommendations related to privacy training, Fox said the health authority should review its process for registering patients, which was last updated in 2013.

How this happened

The incidents in question took place in March 2022. They are documented in a report completed by Fox last month and made public last week.

A patient arrived at Yellowknife’s hospital on March 1. We’ll call them Oliver. (This did not actually happen to the author of this article, we promise. We’re using these names to try to make the situation clearer. The real people involved are not identified in Fox’s report.)

Oliver was unconscious, so they could not identify themselves, but the emergency responders had been given a name from an RCMP officer who was at the scene and knew the patient.

According to Fox’s report, the registration clerk at the hospital entered the name provided by emergency responders into the system but discovered “two clients with the same last name, similar first names and birth dates one year apart.”

In other words, imagine a situation where the clerk looks at the list and sees:

• Oliver Williams, 08/08/2000
• Ollie Williams, 08/09/2001

The clerk didn’t have a date of birth to help them decide between the two – the person arrived with no ID on them – and we don’t know for sure if the clerk was given the name Oliver or Ollie by emergency responders.

How the clerk ultimately made a decision isn’t clear, but they chose the wrong option and admitted Oliver Williams to hospital under Ollie Williams’ medical records. (In reality, the names may have been an even closer match. We aren’t given that information.)

That initial mistake triggered a series of mishaps and missed opportunities to rescue the situation.

First, the health authority tried to contact next of kin – but called Ollie’s next of kin instead of Oliver’s, since they thought they were treating Ollie, and got no answer. So there were no family members to realize something was amiss.

Oliver needed to be medevaced to Edmonton. On arrival, Alberta healthcare workers assumed the patient had arrived under the correct identity, so they thought Ollie had entered the building and no further checks took place.

The patient regained consciousness once in Edmonton, but this did not solve the problem. When healthcare workers used the name “Ollie” to address Oliver, Oliver didn’t bat an eye.

The health authority later discovered “Client B’s first name was also a nickname used by Client A, so it was not unusual for Client A to respond to this name,” Fox wrote.

Applying that to our version: since Oliver was called Ollie all the time by friends, they had no reason to think anything was amiss when people called them Ollie.

Back in the NWT later that month, staff continued to treat Oliver as though they were Ollie and nobody – including Oliver – appeared to notice.

Finally, on March 22, a student nurse asked Oliver for their full name and date of birth (which health authority protocol requires before providing care) and noticed a discrepancy between the date of birth Oliver gave and the one in Ollie’s records. As a result, the three-week-long error was fixed and both patients’ records were corrected.

Registering an ‘unknown client’

Fox noted there had been a “repeated failure” to properly identify the patient but the student nurse, by contrast, had acted “quickly and appropriately.” The privacy breach had been handled promptly after that point, he wrote, including notification of Alberta Health Services.

While the NWT’s electronic records do have an alert mechanism for patients with similar names, designed to prevent this sort of mistake, Fox said it isn’t foolproof, doesn’t apply to paper records and relies on staff “remaining vigilant.”

A final report was sent to Fox in March 2023. Fox’s office, which has its own backlog of privacy cases to deal with, published his report just over two and a half years later.

The health authority could be clearer about its definitions of known and unknown patients, Fox wrote, and there should be “an explicit direction that when a client cannot be identified using two person-specific identifiers” – like full name and birth date – “they should be registered as an unknown client until their identity can be confirmed.”

“Without some form of constant reminder that privacy protection is required at every point of the health service delivery process, employees can become complacent in the belief that clients have been correctly identified upon registration and that verification at every interaction is not necessary,” he concluded.

“This privacy breach serves as an example of the impact of complacency and lack of due diligence for privacy protection during the delivery of health services.”