A better system of safety measures is needed to make sure patients are not mixed up and given the wrong invasive procedure during outpatient appointments, according to the latest report from the Healthcare Safety Investigation Branch (HSIB).
The report is based on a national investigation triggered by the case of a 39-year-old woman who attended a gynaecological outpatient clinic for a fertility treatment assessment, but received a colposcopy meant for another patient.
The misidentification happened at the point of calling the patient through from the waiting room as the patients had similar sounding names. No other checks were done to confirm her identity and there were further examples of confusion during the appointment, which meant the error was only realised after the patient had left.
Although this type of incident is not isolated, it is not widely reported and there are little data captured on the scale and impact of misidentification of patients, specifically in an outpatient setting, according to HSIB. This is despite outpatient appointments rising from 54 million to 94 million over the last 10 years.
HSIB found that the risk of misidentification in the outpatient environment was not well understood and there was a lack of clarity over the contributing factors. As a result, HSIB’s national investigation focused on analysing the effectiveness of existing safety controls and identifying the key factors that contribute to the risk of a patient misidentification. This included:
- Reliance on verbal communication.
- The physical environment.
- Clinical workload.
- Design of the tools used to assist with patient identification.
- Lack of integration of technology in outpatient departments.
- Impact of patients moving around department.
The report concludes with one safety recommendation - that NHS England and NHS Improvement lead a review of risks relating to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise.
