A doctor and investigator discussing a file in a hospital corridor.

HSIB publishes first local investigation pilot report focused on incorrect patient identification

by Communications team

The first report from HSIB’s local integrated investigation pilot has now been published.

The local pilot, launched in May 2021, aims to evaluate HSIB’s ability to carry out effective investigations with actions aimed at specific trusts or hospitals, while still identifying and sharing relevant national learning. This report, alongside an evaluation programme for the pilot, will be used to consider whether this is a model that HSIB can implement more widely in the future.

HSIB connected with several acute trust hospitals and ambulance trusts and asked them to refer safety events that involved cross-boundary care. Within five days of the referral set out this first report, we launched an investigation focused on the impact of incorrect patient identification.

We investigated the case of a 75-year old woman who was taken to A&E by ambulance, where incorrect details were handed over from the ambulance Trust to the acute Trust.

Following the 999 call from her granddaughter, the emergency operations centre had attributed the wrong NHS number to the patient, using the number of someone with the same date of birth and similar name. As a result, the patient was booked into hospital using an incomplete name and the second patient’s NHS and hospital numbers. The incorrect details continued to be used during the patient’s hospital stay, leading to medication for the second patient being prescribed for her in error.

The investigation focused on the key communication points in the patient’s care pathway where details of the patient’s identification were handed over. It also looked at the identification systems and processes in place at both Trusts.

The report sets out 15 findings relating to the local investigation, covering areas such as cultural conventions associated with names and dates (the patient was from a South Asian community), gaps in identification processes and polices, both at ambulance handover and across the hospital, the inconsistent use of the NHS number and the inoperability of digital systems. These findings formed the basis of the safety recommendations and observations that were then directed to the Trusts for action.

The report also highlights safety risks that might be addressed by a potential future national investigation and identified three learning points for national benefit.

Helen Jones, National Investigator says; We worked with staff at both Trusts and the patient and her family to build a detailed picture of what happened so we could identify the areas of learning associated with this specific case of incorrect identification.

"Tailoring safety recommendations to Trusts allows them to address particular safety concerns and close gaps in their procedures, reducing the likelihood that similar incidents will happen again. Both Trusts have or are in the process of implementing the four safety recommendations, which are aimed at improving cross-boundary care for all their patients.”

Dr Nick Woodier, Chair of the pilot steering group says; “ The purpose of the local pilot is to understand where HSIB can add value at a local level, whilst using our unique remit and profile as a national body to share what we find for the benefit of patients and staff across the whole country.

"The local investigations still hold the core HSIB principle of taking a no-blame approach and they bring together the experience and expertise of investigators from across the national and maternity programmes. As the investigations progress, we continue to gather insight from across HSIB and externally so that we can fully evaluate the pilot’s effectiveness and set out what a wider future implementation of this could look like.”

The final evaluation report is expected in early 2022, once all investigation reports have been completed.

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