Hospital performs tonsillectomy on wrong patient

Hasbro Children's Hospital in Providence, RI, has admitted to a serious
medical error, during which a tonsillectomy was performed on the wrong girl
last week. Staff at the hospital confused the patient with another girl who
had a similar first name, according to the Boston Globe. 

Hospital officialssay they have launched an exhaustive internal investigation, and RhodeIsland health officials are also involved in an independent probe. Two
hospital employees were disciplined for the mix-up, and the hospital is
examining its own system of checks and balances to figure out how the error
occurred. 

The incident was revealed to the public when a hospital employee
overheard others talking about the event and phoned a local TV station.

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Bill Corcoran Challenge: Please describe at least seven missing and/or ineffective barriers that could have prevented this event. Add your own file or send out a posted message.