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Written on 15th February 2024 by Richard Money-Kyrle

Healthcare safety watchdog, HSSIB, has warned that patients are at risk of harm from patient identification errors during their NHS treatment.

HSSIB’s national learning report, Positive Patient Identification, draws on the findings from previous investigations carried out by the former HSIB into the patient safety risks from patient misidentification.

HSSIB’s Positive Patient Identification investigation highlights the findings of previous research showing that misidentifications accounted for 70% of adverse outcomes, including reactions to being given the wrong blood, unnecessary surgery and delayed cancer diagnoses; up to one fifth (20%) of misidentifications in laboratories resulted in patient harm. They highlighted that the Emergency Care Research Institute’s investigation of 8000 wrong-patient events from 2013 and 2015 included events that resulted in patient deaths. A review of Strategic Executive Information System (StEIS) revealed 171 reports of seriously and potentially harmful patient misidentification incidents from April 2017 to December 2022. Former HSIB have also carried out maternity investigations relating to the misidentification of women and babies.

HSSIB warns that without further work to understand and manage the risks from misidentification these errors will keep happening and more patients will suffer serious harm. This is because current controls to prevent patient misidentification have limited effectiveness, and whilst HSSIB believes it could be possible to reduce the number of patient identification errors, NHS England are unable to allocate more resources to address this risk.

The importance of patient identification

HSSIB defines positive patient identification as correctly identifying a patient to ensure that the right person receives their intended care. The types of care that can be affected by mistakes in correctly identifying a patient range from diagnostic tests to routine appointments, surgery or the way in which a patient is treated a medical emergency.

Correct patient identification must take place every time a patient has contact with healthcare professionals, which may be often during long periods of care. The process involves initially identifying the patient and also repeatedly confirming their identity at each intervention or stage of their ongoing care. National and local (e.g. hospital) guidance sets out how identification at each stage of care should take place.

HSSIB says patient misidentification remains a persistent risk to patient safety   

Patient misidentification is a mistake in which the patient is incorrectly identified as someone else. Misidentified patients may not receive the care that is meant for them or they may receive care that is inappropriate because it was meant for someone else.

The safety risks from patient misidentification have been highlighted repeatedly to healthcare organisations over the last 20 years, including by the National Patient Safety Agency, by Serious Hazards of Transfusion (SHOT), and in guidance and alerts. Despite these warnings, HSSIB’s latest investigation found that patient misidentification remains a persistent risk to patient safety that can result in significant harm. Cases of misidentification continue to occur with patients suffering significant physical and psychological harm as a result of being misidentified as someone else.

The former HSIB received case referrals and carried out investigations into patient misidentification which showed the harm caused to patients who were misidentified and underwent procedures not intended for them or did not receive correct emergency care. Several of these patients went on to receive further treatment under the wrong identifiers when the identification mistake was not picked up by further verification processes during handovers of care, referrals, or during tests and treatment. At each of these stages in their care, local policies existed which required the patient’s identity to be verified, but in practice no ongoing verification of their identity took place.  

In most cases, misidentifications were eventually recognised by the patients or their families, and in two cases by hospital laboratories which received samples for blood transfusion requests. HSSIB points out that patients may not always be able to recognise that they have been misidentified and even when this was queried their concerns were not acted on by healthcare staff.  

Risk of harm to patients from misidentification is underestimated by healthcare services 

HSSIB are concerned that even though the potential for harm from patient identification errors is known, the likelihood of it occurring is underestimated by healthcare services. Under-reporting of safety incidents, incorrect reporting of misidentifications as administration errors and lack of understanding of these errors may all contribute to the underestimation of the risk of harm. Lack of understanding is increased by varying levels of risk to patients depending on the situation and healthcare setting in which the patient is identified. Two former HSIB investigations found that patient misidentification was a hidden risk in the healthcare organisations, so the extent of the problem and the risk was unknown.

What did HSSIB’s Positive Patient Identification investigation find?

The overarching message from HSSIB’s Positive Patient Identification national investigation is that the scale and complexity of the risk from patient identification errors are misunderstood, challenging, inadequately controlled and addressed but continue to threaten patient safety at each stage of the patient’s care, with the potential to cause serious harm. 

HSSIB found that positive patient identification is seen as a routine task, but it is common, complex and critical for patient safety. Correct patient identification relies on staff following instructions in policies and procedures, but these are not always fully appropriate in the situations in which staff are identifying patients.

Patients are known to be at higher risk of misidentification in high-risk situations and settings, such as during handovers, patient transfers, emergency care, laboratory investigations, medication processes, invasive procedures and diagnostic x-rays and scans. In addition, HSSIB found that local policies and their implementation, high workloads requiring staff to trade efficiency for thoroughness, and limited management of safety risks were all factors increasing the risks of mistakes in identifying patients correctly.  HSSIB emphasised that current controls cannot prevent all misidentifications, but more could be done to support staff in identifying patients by improving their working conditions, particularly in higher risk situations and settings.  

HSSIB concluded that part of the problem is that the risk of patient misidentification is underestimated and misunderstood, which restricts the resources that hospitals and national organisations, such as the NHS, can allocate to reduce that risk. They illustrate this by the response that was received from NHS England and NHS Improvement to a safety recommendation by the former HSIB, which said: ‘Our assessment is that this work would require determination of the true scale and impact of the risks identified … At this time, there is insufficient evidence that the scale of this risk would justify such a reallocation of the available resources’. Meanwhile, patients continue to suffer serious harm as a result of inappropriate or incorrect treatment or missing out on intended care as a result of too many healthcare cases of mistaken identity.

Technology alone cannot reduce the risk of patient identification errors

HSSIB point out that technology alone is unlikely to reduce the risk of patient misidentification. Work systems involving people, technology and tools must be designed to improve patient identification processes. HSIB’s and HSSIB’s investigations have found issues with reliance on technology to reduce misidentification including limited awareness of the ways in which electronic systems can support patient identification, such as by matching patients to records and flagging patients with similar names. They found that staff were not properly trained on these systems, and the design of their working environments and the technologies used all increased the risk of patient misidentification. In addition, many software systems did not offer alerts, prompts or forced stops to prevent the inputting of incorrect patient information. Staff were also restricted by limited availability of computers or handheld devices, limited battery life and log-in problems. The risk of patient identification errors was also increased when paper and digital systems were used alongside each other.

HSSIB calls for consistent use of the NHS number to reduce ‘wrong patient’ errors

HSSIB concluded that the risk of patient misidentification is currently not controlled. The main control for preventing patient identification errors in England and Wales should be each patient’s unique 10-digit NHS number. HSSIB found that use of the NHS number for identification was limited and varied, despite guidance on patient identification mandating the use of the NHS number to identify patients.

Each person has a unique 10-digit number that is assigned to them at birth or the first time they receive NHS treatment. They keep the same number for life, with new numbers only being issued in exceptional circumstances such as adoption or gender reassignment. The NHS number appears on most NHS documents that relate to their care, including prescriptions, test results and appointment letters. In healthcare settings the NHS number should be used together with other identifiers, such as the patient’s name, date of birth and address, and may be printed on the patient’s wristband in a hospital setting.

Multiple previous HSIB investigations have highlighted healthcare staff’s failure to use the NHS number to ensure correct patient identification. Possible reasons included unsupportive working conditions, environments and technology which hinder the use of the NHS number, or hospital processes which lead staff to adapt their practise, such as hospitals asking staff to use the patient’s hospital number instead. 

Patient identification processes must take into patients’ needs

HSSIB also noted that the designs of current software and identification processes do not take proper account of local populations or the diversity of patients’ needs, increasing the risk to patients who do not speak English, or are unconscious, or who cannot self-identify because of memory, reasoning or communication difficulties, and to those from populations with certain naming and date-of-birth conventions.  Policies and procedures largely focussed on patients who could answer questions about their identity, and relied on families and carers to provide identification for those who could not self-identify.

Where patients were misidentified, HSSIB noted difficulties in correcting the misidentification and ensuring that the patient’s records were accurate.

HSSIB identified that previous efforts to significantly reduce the risks have not been successful. They recommended a change of approach away from simply waiting for and reacting to evidence of harm, to the more modern and active adoption of processes which ensure that patients are safe.

If you or a family member have suffered severe injury as a result of medical negligence or have been contacted by HSSIB/MNSI or NHS Resolution you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.