Source · HSSIB Patient Safety Investigation
Positive patient identification
HSSIB’s introductionWe've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and identifies how these misidentifications have been able to happen.
Published 8 February 2024
Launched 5 July 2022
Published
Communication and decision making
Checking
Indexed content
4 recommendations
6 observations
2 actions
3 of 4 responded
Safety Recommendations
HSSIB recommends that NHS England assesses the priority, feasibility and impact of future research to quantify and qualify the risk of patient misidentification. This is to support future prioritisation of work programmes to improve safety in high-risk situations and settings.
AI-generated response summary NHS England has assessed the evidence, developed a policy research request for patient misidentification, secured approval from its RNP, and received prioritisation from DHSC. Discussions are ongoing with NIHR regarding research scope.
Response received 14 March 2024
NHS England’s National Patient Safety Team conducted an initial assessment of the evidence base, to determine what is already known about this issue and engaged with a wide range of stakeholders with a broad range of knowledge, skills and expertise to develop research question(s) to address the evidence gap that was highlighted in HSSIB’s report. A previously published HSSIB report identified safety risks from patient misidentification and limited access to critical information at the bedside. One of the safety recommendations (HSIB safety recommendation R/2023/215) was that NHS England assesses the priority, feasibility, and impact of future research into what and how critical information pertaining to the emergency care of patients in the acute hospital setting can be readily and reliably accessed at a patient’s bedside. The team identified a strong link between positive identification and access to accurate critical patient information. Therefore, it was pragmatic to address both issues in a single research request. Subsequently the team developed and submitted a request for policy research for the two safety recommendations (i.e. R/2024/017 – Positive Patient Identification AND R/2023/215 - Access to critical patient information at the bedside) to NHS England’s Research Needs Panel (RNP) in July 2023. The RNP is NHS England’s in-house process to review, agree and prioritise policy research needs for formal submission to the Department of Health and Social Care's Research and Development Committee. The panel is made up of representatives from all directorates of NHS England. The RNP subsequently approved the request and so formal submission of the research request was made to the Department of Health and Social Care’s Research and Development Committee. The request was prioritised by that committee in October 2023. Discussions are now (March 2024) ongoing with the National Institute of Health and Care Research (NIHR) to agree the research scope and the potential commissioning routes. Response received on 14 March 2024.
HSSIB recommends that the Care Quality Commission develops its methodology for assessment of integrated care systems and organisations to include arrangements for the positive identification of patients at transfer between healthcare organisations. This is to reduce variability in processes and what information is used for identification.
AI-generated response summary CQC states that due to ongoing external healthcare reviews, clarity on their response cannot yet be achieved, and an updated response will follow when more information is available.
Response received 30 April 2024
Original response received on 30 April 2024. Due to external healthcare reviews underway clarity on response cannot be achieved, this will be updated when more information is available.
HSSIB recommends 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.
AI-generated response summary NHS England's NPST supports the existing Scan4Safety programme, has updated resources, and is reviewing the strategic aims of S4S support to scale and spread scanning technology for patient identification, particularly for misidentification, by March 2025.
Response received 1 May 2024
As described in the HSSIB report Scan4Safety enables products and people to be tracked through the supply chain and across hospitals. Scan4Safety was first introduced in 2016 as a pilot funded by the Department of Health to work with six demonstrator sites to investigate how consistent use of point of care scanning might improve efficiency and safety within the NHS. Implementation requirements for adopting Scan4Safety (S4S) for positive patient identification were developed as part of this initial S4S work. The report ‘A Trust’s guide to positive patient identification’ can be accessed via the recently updated Scan4Safety website . NHS England’s National Patient Safety Team (NPST) support the S4S programme by providing national advice, support and guidance to NHS organisations interested in adopting or improving approaches to ensure the traceability of medical devices and other products used in health and social services safely. The NPST recently updated the S4S website to help organisations find the resources they need to promote S4S locally. The website is supported by GS1 and received input from other key stakeholders. The NPST have also launched an interactive NHS Futures page with more hands-on tools for providers to use locally. To further our support to the system, the NPST work closely with other national organisations (MHRA, NHS Supply Chain and GS1), people who use services and NHS trusts in line with system requirements to increase the uptake of safe and effective scanning technologies. The team is currently reviewing the strategic direction of the S4S support offering and the potential to scale and spread the use of scanning technology to improve patient safety including reducing patient misidentification. Action planned to deliver safety recommendation: Review strategic aims of the S4S support offered by the national team to ensure workstream is delivering impactful scale and spread of the use of scanning technology to improve patient safety. This will include an emphasis on patient misidentification. By March 2025. Response received on 1 May 2024.
) and the resources available to address it have been considered, practicability may need to be considered nationally.
No response is indexed for this recommendation.
Safety Observations
Future improvement programmes considering the risk of patient misidentification can improve patient safety by prioritising high-risk situations and settings, such as handovers and transfers of patient care. Multiple controls may need to be introduced, including new technologies and standardising of processes.
Healthcare organisations can improve patient safety through the use of principles of ‘user-centred design’ to help them understand and optimise clinical work settings for positive patient identification.
Those designing patient identification processes, including related software, can improve patient safety by undertaking effective equality impact assessments and by considering the needs of specific patient groups that are at high risk of being misidentified.
Those purchasing and implementing electronic patient record systems in healthcare organisations can improve patient safety by ensuring those systems are compliant with relevant risk management standards (such as DCB0129, DCB0160 and DCB1077).
Healthcare services can improve patient safety by seeking to better understand and address the risks associated with positive patient identification through a safety management system approach.
Healthcare organisations can improve patient safety by assessing and addressing their local barriers to using the NHS number for patient identification.
Safety Actions
HSSIB suggests that integrated care boards assure processes for the transfer of patient care between healthcare organisations in their geographical footprints to reduce variation in processes for patient identification.
HSSIB suggests that integrated care boards assure that where a patient misidentification has occurred, healthcare organisations in their geographical footprints have collaborative processes to learn why and to ensure health records are correctly allocated.