Prague hospital cites staff negligence in patient-mix up that led to miscarriage

Bulovka University Hospital said an employee failed to identify a case of mistaken identity that caused a healthy pregnant woman to miscarry.


Written by ČTK Published on 04.04.2024 14:40:00 (updated on 05.04.2024) Reading time: 2 minutes

Two employees were found responsible for the tragic mix-up of female patients leading to an unintended miscarriage at Prague’s Bulovka University Hospital, the hospital's director Jan Kvaček announced at a press briefing today, citing results from an internal analysis.

One of the implicated employees remains off duty, and the hospital will address the continued employment of this individual. The other employee will stay at the hospital but will work under supervision, Kvaček added.

Due to the error, a healthy pregnant woman who had come for a routine check-up miscarried after undergoing curettage surgery, a procedure designed to remove tissue from inside the uterus. 

Kvaček apologized to the patient on behalf of the hospital and is currently negotiating compensation with her.

Both patients involved were foreign women from Asia residing permanently in the Czech Republic, as reported by the media. One was pregnant and had visited Bulovka Hospital for a routine check-up, while the other required curettage – a procedure used to treat uterine diseases or terminate a pregnancy. Unfortunately, the staff members mixed up their identities.

Michal Zikán, head of the gynecology and obstetrics clinic at Bulovka Hospital, stated: "If someone mistakenly identifies the woman incorrectly, this may happen. But the other person has the apparatus, including written protocols, to reveal the error."

He added that patients must provide their names and are equipped with safety bracelets. Zikán also mentioned that the patient signed a document in Czech identifying another patient.

"The patient was thoroughly informed three days prior, even in the presence of an interpreter, regarding what to expect – she was going for an outpatient check-up and blood sample collection," he said, noting that further details cannot be disclosed due to patient confidentiality.

"The staff involved had no reason to suspect from the patient's reactions that it was someone else," he noted. The patient was addressed in a standard manner and responded to someone else’s name, including looking at the documentation, he added. The hospital is still trying to understand why she went ahead with the procedure.

Zikán acknowledged the failure of the hospital to correct the mistaken identity during the second step of an accredited external process meant to identify errors.

Kvaček said that until the hospital completes its investigation, patients with language barriers will be more prominently tagged. "We have proposed measures that may be excessive at the moment but certainly provide security not only to patients but also to medical personnel," added Zikán.

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