Source · HSSIB Patient Safety Investigation
Local integrated investigation pilot 1: Incorrect patient identification
HSSIB’s introductionBetween April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
Published 22 March 2022
Launched 6 August 2021
Published
HSIB Legacy
Analysis
Indexed content
3 recommendations
4 observations
3 actions
3 learning prompts
2 of 3 responded
Safety Recommendations
HSIB recommends that the Ambulance Trust develops and implements a standardised approach to patient identification in the emergency operations centre.
AI-generated response summary The Ambulance Trust implemented updated training and staff updates on search functionality and requirements for patient identification in the emergency operations centre.
Response received 4 February 2022
The Ambulance Trust responded to this safety recommendation and described their following actions: Updated training for staff around search functionality in their patient demographic service. Staff update on search requirements and confirmation of patient information. Response received on 4 February 2022.
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.
AI-generated response summary The Acute Trust's ED will review practices, information sources, and layout to resolve barriers to checking three identifiers for wristbands, and reinforce the identification policy.
Response received 25 February 2022
The Acute Trust responded to this safety recommendation and described their following actions: The Emergency Department will review practices, patient information sources and department layout to resolve the barriers to checking three patient identifiers when applying name bands. If required by the above review, the Trust will review data items printed on the identification band and modify these to support the identify checking process. Local reinforcing of the Trust’s identification policy. Response received on 25 February 2022.
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.
HSIB makes the following safety observations
No response is indexed for this recommendation.
Safety Observations
It may be beneficial if the Ambulance Trust develops mechanisms to capture the NHS number at the point of initial contact.
It may be beneficial if further national work is undertaken on the use of the NHS number as a unique identifier, specifically in identifying patients.
It may be beneficial if the Acute Trust considers the interoperability of its IT systems (that is, the ability of different IT systems to communicate and share information) as part of its digital strategy and in future procurement.
It may be beneficial if the Ambulance Trust adjusts its call audit tool to assess whether patient identification is correctly confirmed.
Safety Actions
The Ambulance Trust training department has implemented training on patient demographics within its test system. Emergency operations centre staff receive this training during their formal induction.
The Ambulance Trust is designing a confirmation checkpoint, which will be included in the electronic patient record for ambulance crews to confirm the correct identification.
The Ambulance Trust now includes the importance of patient identification, including using the NHS number to verify a patient’s identification, in its mandatory training.
HSIB notes the following specific national safety risk
The NHS number is a unique identifier for people living in England (and Wales). There is a chance that a patient may be incorrectly identified when the NHS number is not used.
Learning Prompts
‘Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020’ (Healthcare Safety Investigation Branch, 2021a)
‘Electronic prescribing and medicines administration systems and safe discharge’ (Healthcare Safety Investigation Branch, 2019a)
‘Management of chronic health conditions in prisons’ (Healthcare Safety Investigation Branch, 2019b).