HSIB: Local integrated investigation pilot 1. Incorrect patient identification (25 November 2021)

Summary

This report by the Healthcare Safety Investigation Branch (HSIB) has been published as part of a local pilot, which has been launched to evaluate HSIB’s ability to carry out effective investigations occurring between specific hospitals and trusts. After an evaluation, it will be decided whether this model can be implemented more widely by HSIB.

This investigation reviewed the case of a woman who was taken to an emergency department by ambulance in April 2021, following a 999 call from her Granddaughter to the emergency operations centre. The emergency operations centre used the wrong NHS number for the patient, which was assigned to her for the duration of her stay in hospital and led to her being offered incorrect medication.

Content

On her admission to hospital, the patient had been assigned the NHS number of another patient, who had the same date of birth and a similar name. During her stay she initially received medication prescribed to her based on her own supply, brought in by her family. However, following a pharmacy review on day 7 of admission, the medications were changed to those of the patient whose NHS number she had been incorrectly assigned. The patient declined to take the incorrect medication and the error was subsequently identified by a pharmacist the following day.

Findings

The investigation identified the following learning points for potential national benefit:

• The correct identification of patients relies on staff checking patient details, and therefore will not always occur effectively. There may be opportunities for further engineered or technological barriers to decrease the chance of incorrect identification.
• The design of the digital systems considered in this investigation did not always account for variations in how people identify themselves (for example, by different names). Those systems also did not make it clear to staff where patient demographics (that is, details such as the patient’s name, date of birth, address and NHS number) might be incorrect.
• The investigation recognises that a single hospital trust may receive patients from multiple ambulance trusts, and ambulances from a single trust may go to several hospital trusts. Pathways and processes potentially vary across different trusts and a consistently agreed approach may not exist.
• The use of NHS numbers to identify patients may vary across the country. The investigation found that the NHS number may not be being used according to national expectations.

Recommendations

The report makes the following local safety recommendations:

• HSIB recommends that the Ambulance Trust develops and implements a standardised approach to patient identification in the emergency operations centre.
• HSIB recommends that the Acute Trust develops and implements a standardised approach to patient identification in the emergency department.
• HSIB recommends that the Acute Trust explores the barriers to checking three identifiers when confirming a patient’s identification for their wristband, and takes appropriate action.

The report also made the following regional safety recommendation:

• HSIB recommends the Acute Trust work with the Ambulance Trust to develop and implement a standardised approach to verifying and confirming a patient’s identification during the handover process.

Response from Patient Safety Learning

Patient Safety Learning welcomes the publication of this report and HSIB exploring new approaches to their patient safety investigations through this pilot programme. Our reflections on this report are as follows:

Wider value of these findings

In their report HSIB make four recommendations relating to the Acute Trust and Ambulance Trust in this case. It may be that there are similar issues occurring in other trusts across the country and that there would be value in NHS England and NHS Improvement reviewing patient identification processes more broadly in line with these findings. We would also suggest it would be helpful if NHS England and NHS Improvement could identify examples of patient identification good practice that could be shared more widely.

Role of patient and family engagement

HSIB states in its report that the patient, when offered the incorrect medication, declined this, but for unclear reasons. It also notes the role played by the patient’s Granddaughter in identifying this error on two separate occasions:

• On the first day she alerted staff to incorrect information on the patient’s wristband, but no record was made of this.
• On the fifth day she alerted staff to an error regarding her grandmother’s details on medical records.

It is notable however that the error was not formally addressed until the pharmacist noticed a discrepancy and confirmed this was an error when speaking to the patient’s Granddaughter. We believe this serves to underline the importance of engaging and listening to patients and their family members. This patient safety issue may have been identified and addressed much more swiftly if the patients Granddaughter’s concerns about incorrect patient information had been followed up on appropriately.