Rationale for Selection of Case Study-1

• This  case (1) is hands-on experience of one of our teammates who directly involved in it when it was happened.
• This case encompasses the in depth analysis, interpretation and discussion on how one of the patients got wrong test
report due to similar sounding names that lead a staff to confuse that results in wrong chart for the patient.
• This kind of cases often attributed with incomplete conversations that lead a patient to serious health condition.
• This case illustrates, a variety of communication lapses might contributed to patient pathology test report within
complex health care system. Awareness on communication barriers should alert to staffs in order to rectify the
problem.
• In this case, how communication lapses lead to misidentification and increase the likelihood of adverse events.
Identifying patients with such barriers, devoting extra attention to communication, and developing systems for
improved interpreter services may all serve as important patient identification strategies.