I drive Uber during breaks between contracts for health IT work. Recently, I picked up a younger Asian woman at a DC-area Metro station on a sunny afternoon. I’ll call her CJ — not her real name.After the usual pleasantries, we started talking about work. When I mentioned my job — detecting errant clinical data in the wrong patient record — she sat up straight and interrupted me. “I need to tell you what happened to me,” she said.
A Visit to the ER Gone Wrong
CJ had recently gone to a local emergency room for what she feared might be appendicitis. During the evaluation, a physician casually asked her if she was taking her medications.
“No, I don’t take any medications,” CJ replied.
The doctor checked her chart and, with confidence, said, “Yes, you’re on haloperidol for your condition.”
Haloperidol — an antipsychotic used to treat schizophrenia.
CJ was stunned. She explained that she’d never taken such a medication and had no psychiatric history. But the physician insisted — her record showed a history of schizophrenia and a long-standing prescription for the drug. He confirmed her name and demographic details, then excused himself from the room.
And left her — in pain and untreated.
“I felt helpless, confused, and frustrated.”
Misbeliefs Multiply
Several minutes later, a male nurse came in to review her chart. Like the doctor, he trusted the screen more than the patient sitting in front of him.
He asked her about her three children.
“I don’t have children,” CJ said, again confused and alarmed.
What should have been a routine diagnostic process became a distressing back-and-forth. The nurse questioned her identity, her medical history, and her reality — delaying her treatment and shaking her trust in the healthcare system.
Eventually, she was diagnosed and treated for something other than appendicitis. But the damage had been done.
A Diagnosis That Wasn’t Hers
Later, at home, CJ’s mother looked up one of the medications prescribed upon discharge. It was, once again, an antipsychotic. A drug for a condition CJ didn’t have.
CJ tried to tell the providers their records were wrong. But no one listened. She left the ER feeling helpless, confused, and traumatized — one of many patients who shared their story with me during the Uber ride. CJ, like others, was caught in the all-too-real consequences of a wrong-record error.
What Likely Happened
After hearing her story, I suspected what might have gone wrong: it’s likely that another patient’s medical record had been merged with CJ’s record, and her demographic data was chosen as the “surviving” record — possibly because she had more recent visits.
This kind of error are caused by human error. In this case, someone made the wrong decision that two different patients were the same and merged their records. Once merged, the resulting “golden record” contains data from two different people — creating a dangerous situation. Health information management (HIM) professionals call these kind of errors “overlays” but I prefer the name used by clinical informaticists that more broadly describe the errors as “wrong-patient errors” (WPEs).
How CJ Can Take Action
I encouraged CJ to get a copy of her medical records from every provider she’d seen in the last few years and review each one carefully for errors. Using the standard Release of Information (ROI) process, she could begin to untangle her record from someone else’s.
She was grateful. “Thank you so much,” she said, repeatedly. “You’ve given me a place to start.”
Why This Matters
CJ’s experience is not an isolated incident. Wrong-patient errors affect real lives, real health outcomes, and real trust. They are not just technical mistakes — they’re deeply human ones.
As healthcare professionals, we must:
- Invest in strong patient matching systems and data governance.
- Train providers to trust, but verify — and listen to patients when something does not add up.
- Empower patients to regularly review their records and be sure they understand the process to correct errors.
No one should leave the hospital feeling like a stranger in their own medical story.