HSSIB National learning report: Positive patient identification (8 February 2024)

Summary

This national learning report (NLR) draws on findings from investigation reports completed by the Healthcare Safety Investigation Branch (HSIB) that considered the risks associated with patient identification. ‘Positive patient identification’ is correctly identifying a patient to ensure that the right person receives their intended care. To support patient identification in England, the patient’s NHS number should be used alongside other identifiers, such as their name, date of birth and address.

Patient misidentification is where a patient is identified as someone else. This may mean that a patient does not receive the care meant for them, or that they receive the care meant for someone else. Patient misidentification was highlighted as a risk to patient safety by the National Patient Safety Agency in the early 2000s. Despite the time that has passed, patient misidentification remains a persistent risk to patient safety that can result in significant harm.

The aim of this NLR was to combine and analyse HSIB’s previous investigations and relevant international research literature, with the goal of informing national learning and influencing national actions to help reduce the risk of patient misidentification.

Content

Findings

• Patient misidentification is challenging to address and previous efforts to reduce the risk have not been as successful as hoped. There may be a benefit in proactively ensuring that processes for identifying patients are safe, rather than reacting to incidents of harm.
• Positive patient identification is seen as a routine task, but is common, complex and critical for patient safety. It relies on staff following instructions described in policies and procedures, which might not always be fully appropriate to the circumstances within which staff are identifying patients.
• Patients are at higher risk of being misidentified in certain situations and settings. Examples include handovers and when care is transferred between different healthcare organisations.
• The risk of patient misidentification is underestimated and patient misidentification can result in significant harm to patients. Under-recognition of the risk is preventing allocation of already limited safety resources to further mitigate the risk.
• The main control in preventing patient misidentification in England is the NHS number. However, there is sometimes no, varied or limited use of the NHS number in clinical practice due to various factors.
• Technology alone is unlikely to reduce the risk of patient misidentification. Work systems involving people, technology and tools need to be designed to improve identification processes.
• The designs of current software and identification processes may be disadvantaging some patient groups (for example, patients with a disability or of certain cultural backgrounds) due to limited consideration of their needs.
• It is not yet possible to eliminate the risk of patient misidentification. However, a series of interventions – including using new technologies and optimising workplaces – may help to reduce the risk.
• When a patient is misidentified, it is difficult to correct the misidentification and ensure their records are made accurate.

HSSIB makes the following safety recommendations

• HSSIB recommends that NHS England assesses the priority, feasibility and impact of future research to quantify and qualify the risk of patient misidentification. This is to support future prioritisation of work programmes to improve safety in high-risk situations and settings.
• HSSIB recommends that the Care Quality Commission develops its methodology for assessment of integrated care systems and organisations to include arrangements for the positive identification of patients at transfer between healthcare organisations. This is to reduce variability in processes and what information is used for identification.
• HSSIB recommends that NHS England reviews and identifies system-wide requirements for scanning in positive patient identification. This is to support local organisations to use scanning technology to reduce misidentification incidents.

HSSIB makes the following safety observations

• Future improvement programmes considering the risk of patient misidentification can improve patient safety by prioritising high-risk situations and settings, such as handovers and transfers of patient care. Multiple controls may need to be introduced, including new technologies and standardising of processes.
• Healthcare organisations can improve patient safety through the use of principles of ‘user-centred design’ to help them understand and optimise clinical work settings for positive patient identification.
• Healthcare organisations can improve patient safety by assessing and addressing their local barriers to using the NHS number for patient identification.
• Those designing patient identification processes, including related software, can improve patient safety by undertaking effective equality impact assessments and by considering the needs of specific patient groups that are at high risk of being misidentified.
• Those purchasing and implementing electronic patient record systems in healthcare organisations can improve patient safety by ensuring those systems are compliant with relevant risk management standards (such as DCB0129, DCB0160 and DCB1077).
• Healthcare services can improve patient safety by seeking to better understand and address the risks associated with positive patient identification through a safety management system approach.

HSSIB suggests the following safety actions for integrated care boards

• HSSIB suggests that integrated care boards assure processes for the transfer of patient care between healthcare organisations in their geographical footprints to reduce variation in processes for patient identification.
• HSSIB suggests that integrated care boards assure that where a patient misidentification has occurred, healthcare organisations in their geographical footprints have collaborative processes to learn why and to ensure health records are correctly allocated.