NHS England
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.
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.
Care Quality Commission
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.
NHS England
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.