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Over the last five years, teams at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, had completed at least four different improvement projects focused on increasing adherence to the independent double check (IDC) process. An IDC is when two registered nurses independently check a medication to ensure it is correct prior to administering it to the patient. Like other institutions, the hospital did not require this process for all medications but did require it for a select group of medications considered higher risk if given in incorrect doses, routes or times. For years, the hospital examined and analyzed the process and related policies for administering these medications, but with no appreciable change in medication error rates. The latest efforts included reducing the number of medications that required an IDC, which pleased the nursing staff, but still did not fix the issue. Then, in the summer of 2019, a medication administration error in the PICU triggered yet another root cause analysis of the IDC process. The frustration of repeated analyses and efforts led the team to take a different approach to investigating its practices. They leveraged the expertise of a resident human factors practitioner—an expert in evaluating the interactions of people, tasks, the environment and technology—to lead the analysis.

Further reading HIQA: Annual report of accidental or unintended exposures to ionising radiation in 2019 CQC reports on safe use of radiation in healthcare settings (19 December 2019)

The study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, it did find that 22% of events involved a high-alert medication. The study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, a free-text narrative field in each event was manually reviewed and reported to better understand the nature of errors. Overall, results from our study can help providers identify areas to target for risk mitigation related to medication errors and the use of infusion pumps.

In the report the Coroner states her main concerns as follows: The inquest heard that there were significant delays in patients being seen in secondary care for gynaecological referrals from GPs. The inquest was told that these delays had now increased. In November 2020 the wait time for an appointment was 1 month for an urgent appointment and 4 months for a routine appointment. The wait times now in Tameside for gynaecology were 8 months for a routine appointment and 4 months for urgent appointments. The increase in wait times reflected a national picture the inquest was told and reflected a significant backlog and a rising demand across the NHS. The inquest heard that understanding and application of the NICE guidance on heavy premenstrual bleeding in General Practice was a factor in recognising the risk to her health and that the risks around heavy premenstrual bleeding were not well understood in General Practice and in particular where it was necessary to expedite referral to specialist services. The quality of the documentation in the referral to secondary care form the GP was poor and the inquest was told that this hampered the triage of her case by secondary care. Standardisation of GPs referrals in relation to detail and guidance regarding key information for referral would assist with effective triage and identification of high risk patients by secondary care. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral. This report was sent to the Secretary of State for Health and Social Care and Tameside Clinical Commissioning Group.

This online survey takes five minutes to complete and will contribute to understanding of this potential patient safety risk. Prevention of Future Death reports have been issued on this subject, but without data it is difficult to identify if this is a specific problem, and if it is, how a big a problem.

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.