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Written on 4th June 2021 by Richard Money-Kyrle

Patient safety investigator, HSIB, has recommended that NHS England and NHS Improvement review the risks relating to patient identification in outpatient settings. The recommendation follows HSIB’s investigation into an NHS outpatient clinic mix up which resulted in a patient incorrectly being told she had an abnormal smear result and undergoing a colposcopy (examination of the cervix) intended for another patient. 

HSIB’s latest report,  Wrong site surgery – wrong patient: invasive procedures in outpatient settings, found that despite wrong site/wrong patient surgery accounting for 48% of serious incident ‘never events’ reported within the NHS between April 2019 and March 2020, there remains a lack of guidance or focus on reducing the risk of patient mix ups in outpatient settings.

With increasing numbers of patients receiving surgical treatment in outpatient clinics (instead of being admitted to hospital for inpatient care), the ability to identify the patient correctly is a fundamental requirement for patient safety. It is also essential to ensure that patients can give informed consent to invasive treatment (such as intimate examinations and surgery) and that they receive the correct care.  

What are outpatients and why are they at risk of patient mix ups?

Unlike ‘inpatients’ who are admitted to hospital for surgery or other treatment, ‘outpatients’ visit the hospital for consultations, tests and treatments but do not stay in hospital overnight. The number of patients treated in outpatient clinics has almost doubled in the last 10 years, with many patients now having minor surgical procedures in an outpatient clinic, instead of an operating theatre.

Outpatient procedures are quicker and more convenient for the patient, and cheaper and more productive for the NHS but it takes organisation to manage multiple patients, all needing different treatments, within 15-20 minute time-slots, in a busy environment and ensure they all receive the right care.

HSIB’s review of wrong patient/wrong surgery reports to the NHS national reporting systems identified that incorrect identification of patients is one important reason why patients (in general) receive the wrong procedure. They also found, however, that the number of patients who are misidentified, and the impact of those mistakes, in outpatient settings is unknown.

It may seem to be stating the obvious to say that correct identification of patients is essential to ensure they receive the right procedure. The importance of patient identification processes has been widely recognised and guidance issued by organisations such as the National Patient Safety Agency (NPSA), NHS England and NHS Improvement, and the World Health Organisation, but their focus has been on inpatient treatment and does not properly address the risks which are specific to outpatient care.

HSIB’s findings about risk of patient mix ups and wrong patient surgery in outpatient care

HSIB identified three key threats to the correct identification of patients at different stages of a hospital outpatient appointment:

  • having two patients with similar names in the same waiting area;

  • where a patient is matched to the wrong notes or the wrong clinic; 
  • where a clinician (healthcare professional such as a doctor or nurse) assumes that the correct patient has been presented for treatment.

In examining how trusts address these risks they found:

  • That there were no formal safety controls to manage the risks arising from patients having similar names.
  • They also identified communication as an issue in an outpatient environment where staff speak to patients to check their identity. The risk of misunderstandings may be increased by problems with the environment (busy or noisy), staff workloads, and language or cultural barriers.

In particular, they identified safety risks inherent in a system in which patients are verbally called for their outpatient appointments, including:  

  • the effect of distractions and noise in a busy waiting area;
  • being heard by patients with hearing impairments;
  • when announcements are unclear;
  • the patient’s emotional state.

Each of these factors can lead to the wrong patient responding to the call, increasing the need for reliable identification checks to take place at a later stage in the patient’s appointment to avoid treatment errors.

  • HSIB found that the risk of the wrong patient being selected increased with:
    • multiple different outpatient clinics running at the same time within a department;
    • large numbers of patients required to wait in a similar area;
    • patients needing to make multiple transitions from one place to another within an outpatient department.

Where patients are identified but then required to move between different areas and be seen by different staff within an outpatient department, they are not required to wear or hold any form of identification, such as a wristband, photo ID badge or unique NHS number. This means that continued correct patient identification relies on further verbal checks by each new member of staff. In addition, the patient’s ability to give their full attention to answering questions, checking forms or other identity checks is reduced where they have had difficulty finding the correct waiting area, or are anxious, stressed or emotional about their appointment.

  • HSIB found that despite NPSA guidance which says that for correct identification the patient’s unique NHS number should always be used with other identifiers (first and last name, date of birth), NHS trusts varied in the processes and tools used to identify outpatients and rarely used the unique NHS identifying number. Whereas inpatients were routinely issued with an identifying wristband, outpatients are rarely given a visual means of identification.
  • Whilst HSIB recognised that technology can be used to support patient identification, they found that a lack of integration of technology within outpatient clinics led to staff not using these systems.  
  • HSIB also recognised that increased workload and time pressure in treating large numbers of patients in busy outpatient settings can have a negative impact on the quality of communication and safety checks needed for effective patient identification.

HSIB’s latest report has again highlighted the need for patient safety to be written into all NHS processes, including communication, technology and incident reporting, to reduce avoidable harm to patients and ensure that they receive a safe and acceptable standard of care.

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