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Patient misidentification interventions outlined in new HSSIB report

Current controls are unable to prevent all patient misidentification and a proactive approach should be adopted to support staff in safety management, according to a new report by the Health Services Safety Investigations Body (HSSIB).

Its ‘Positive patient identification’ report states that patient misidentification is an under-recognised, under-researched and persistent safety risk that can result in significant harm.

The report is therefore aimed at supporting national learning and influencing action across England to reduce the risk of patient misidentification.

And it offers a series of safety interventions for healthcare organisations and policy makers to consider when updating safety processes.

‘A complicated array of interacting factors’

The report analysed evidence from six completed Healthcare Safety Investigation Branch (HSIB) investigations alongside research literature and national policy documents.

These misidentification investigations included a patient who received an invasive procedure not meant for them, a patient who bled after receiving anticoagulation medication not meant for them and a patient who did not undergo a resuscitation attempt because it was thought he was a different patient.

‘HSIB investigations identified a complicated array of interacting factors in different healthcare systems that contribute to misidentifying patients,’ the report said.

Positive patient identification is complex and ‘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,’ it added.

Indeed, despite national direction to use the NHS number as the unique patient identifier, the report found that local policies varied in their descriptions of how patient identification should be undertaken. This included what identifiers should be used and the role of the NHS number.

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Reactive approach to preventing misidentification

The report concluded that current controls are unable to prevent all misidentifications, and the traditional reactive approach to safety management is ineffective.

The HSSIB recommends a move towards proactively understanding systems and assuring the safety of processes, as well as targeting opportunities to better support staff by improving working conditions.

‘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,’ the report said.

Prioritising high-risk situations and settings, such as handovers and transfers of patient care, is an area that the HSSIB encourages healthcare organisations particularly focus on to improve patient safety.

And it also championed the effective use of technology such as electronic patient records, electronic prescribing and administration systems, and barcode and QR code scanning, but warned that currently ‘it is not clear which technology is most effective at controlling the risk in different settings’.

As part of its report, HSSIB recommended 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’.

Effective solutions

Commenting on the report, Nick Woodier, senior safety investigator at the Health Services Safety Investigations Body, said: ‘The six HSIB investigations considered misidentification across different areas of NHS care – from outpatient procedures and emergency departments to ambulance services and care homes.

‘The evidence we have collected aligns with research literature and data from national incident databases and emphasises that despite national improvement efforts, misidentification remains a persistent safety risk.

‘Our report offers insight into where effective solutions could be implemented but we recognise that there is difficulty in allocating resources when healthcare organisations tell us that the scale of the problem is not known.’

He added: ‘Our safety recommendations and findings are aimed at influencing national action to better understand the risk and consider how resources can be allocated to drive improvement across England.’

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