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Wrong Patient Documented in Docusys Record

Constraints and Issues:

Docusys CANNOT transfer documentation from one record to another.
Documentation against the wrong patient creates significant additional work for Docusys Support team, Billing personnel and sometimes ORCA Support.
Above all it is a patient safety issue as wrong clinical information could potentially lead to wrong clinical judgment, care and treatment.

Responsibility of the Attending Anesthesiologist and the Anesthesia Care Giver:

It is the responsibility of the Anesthesia team to ensure that the correct patient is selected in Docusys.
To minimize errors, DO NOT start a case prior to the patient actually being in the OR. The patient can be selected but not confirmed until the patient is actually in the OR,
As a secondary check the Anesthesia team needs to verify that the patient information is correct in Docusys during the “Patient Minicheck” step at the start of case when the patient has just entered the room
As a tertiary check during case the Anesthesia team needs to verify that the patient information is correct in Docusys during SCOAP 1 “TIME OUT”

Steps to handle documentation on the wrong patient:

Scenario 1: Wrong Pt. was detected at the time of "TIME OUT" or before OR less than 30-45 minutes has elapsed since the Anesthesia Start Time

Anesthesia team suspends the wrong case by pressing the "LEAVE OR" button.
Anesthesia team logs into Docusys again and selects the correct patient and manually re-enter the missing clinical information including vitals.
Anesthesia team notifies the Docusys support team (598-8695 (phone) / 540-0937 (pager) about the wrong Pt. selection so that they can reschedule the case pertaining to the wrong record and cancel the wrong record.

Scenario 2: Wrong Pt. was detected at a later part of the case and significant data has been already entered.

· If significant amount of data has been captured or you have reached the end of the case, then the documentation will have to be converted into a paper anesthesia record. Notify Docusys team ASAP.

· Complete documentation in Docusys (though wrong patient name), but NEVER close the record in Docusys

· The Docusys Support Team will print the Docusys record for the wrong patient oncle documentation is complete (No outstanding missing required elements)

· The Anesthesia provider will manually correct the patient name, medical record number, age, procedure, diagnosis and other wrong data elements on all pages of the printed record.

· The Anesthesia provider will write the correct patient name, medical record number and encounter number on all pages (bottom left) of the printed record

· Anesthesia provider will write a comment related to why manual correction of the record was necessary and sign and date the comment.

· Docusys support team will make copies of the correct record and distribute it for billing.

· Docusys support team will submit the corrected record for manually scanned into ORCA

· If the record is already closed, the Docusys support team will notify ORCA team to remove the worng record

· Docusys support team will notify the CQI team of this incident.