HSIB: Local integrated investigation pilot 2. Incorrect patient details handover (20 January 2022)

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.

On her admission to her local emergency department (ED) after a fall at her nursing home, Mrs E, a woman aged 93 with dementia, was booked into the ED with incorrect patient details, resulting in a new patient record being created. She was discharged that day but readmitted the next day after a second fall. She was booked into ED with the new patient record (which contained the incorrect patient details) and had an x-ray which confirmed she had a broken hip, subsequently being admitted to hospital for surgery. Mrs E had surgery the next day, during which the pathology department identified a problem with the accuracy of her patient identification information and following surgery her two sets of patient records were merged.

Content

The investigation identified the following learning points that could potentially offer benefits at a national level:

• 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 help mitigate the risk of incorrect identification.
• The investigation recognises that a single hospital trust may receive patients from multiple ambulance trusts, and ambulances from a single ambulance trust may attend several hospital trusts. Pathways and procedures potentially vary across different trusts and a consistently agreed approach may not exist.
• There may be variation across the country in how NHS numbers are used by trusts for identification of patients. The investigation found that the NHS number may not be being used as per national expectations.

Recommendations:

The report makes the following local safety recommendations:

• HSIB recommends that the nursing home implements a mechanism to use care records with the lowest risk of having incorrect personal identification data during interactions with the wider healthcare system.
• HSIB recommends that the Ambulance Trust carries out additional personal identification data verification when a successful Patient Demographic Service search via NHS Spine has not been achieved.
• HSIB recommends that the Acute Trust, in collaboration with the Ambulance Trust, develops and implements a formal emergency department booking-in policy.
• HSIB recommends that the Acute Trust carries out additional personal identification data verification when an NHS number is not available.
• HSIB recommends that the Acute Trust tests its positive patient identification procedure for patients with dementia in order to identify risks and support the development of effective mitigating controls.

The report made the following local safety observations:

•  It may be beneficial if the Acute Trust reviews the infrastructure and layout of the emergency department majors area in order to support the flow co-ordinator to reliably carry out their full responsibilities.
• It may be beneficial if the Acute Trust considers the results of current research to understand whether a way of visually identifying patients with dementia would be appropriate to help positive patient identification.

 The report also notes the following specific national safety risk:

•  The NHS number is a unique identifier for people living in England (and Wales). There is a risk to the accurate identification of patients when the NHS number is not used as the primary patient identifier.

Response from Patient Safety Learning

Patient Safety Learning welcomes the publication of this report by HSIB.

The local investigation highlighted a number of patient safety issues regarding patient identification, many of which relate to a lack of standardisation.

Standardisation can play an important role in improving patient safety, forming a core component of systems that reduce the opportunity for error and avoidable harm. This is not a new concept, many safety-critical industries adopt such an approach very successfully and the importance of this to healthcare is cited in the World Health Organization Global Patient Safety Action Plan.

The findings of HSIB’s report highlight several areas where the failure to adopt a standardised approach can contribute to errors in patient identification:

• Lack of a standardised and consistent patient ‘booking-in’ procedure in the emergency department.
• Variation in how NHS numbers are used by trusts for identification of patients. The findings in this report suggest that in some cases the NHS number may not be being used as per national expectations.
• Differing pathways and procedures between acute trusts and ambulance trusts.

The scope of this HSIB report is concerned with making recommendations at a local level. Patient Safety Learning believes that the issues highlighted above are likely to have wider applications beyond this local context and require a system-wide review and response from NHS England and NHS Improvement.