The report is based on a national investigation triggered by the case of a 39-year old woman who attended a gynaecological outpatient clinic for a fertility treatment assessment. Unfortunately, she received a colposcopy meant for another patient. The misidentification happened at the point of calling the patient through from the waiting room as the patients had similar sounding names. No other checks were done to confirm her identity and there were further examples of confusion during the appointment, which meant the error was only realised after the patient had left.
Although this type of incident is not isolated, it is not widely reported and there is little data captured on the scale and impact of misidentification of patients, specifically in an outpatient setting. This is despite outpatient appointments rising from 54 million to 94 million over the last 10 years. We found that the risk of misidentification in the outpatient environment was not well understood and there was a lack of clarity over the contributing factors. As a result, the national investigation focused on analysing the effectiveness of existing safety controls and identifying the key factors that contribute to the risk of a patient misidentification. This included.
- Reliance on verbal communication – this places heavier reliance on further checks to confirm the identity of the patient and prevent errors. The report emphasises that communication is often a key contributor to patient safety incidents because it can be affected by a range of factors, from the noise in the physical environment to the patient’s emotional state.
- The physical environment – for example, multiple clinics in one department with one waiting room for patients.
- Clinical workload – the time pressure associated with outpatient appointments can have a negative impact on the quality of communication and effectiveness of safety checks.
- Design of the tools used to assist with patient identification – for example, the investigation looked into why the NHS number is not used more frequently as a way of identifying patients.
- Lack of integration of technology in outpatient departments – this means that staff may not access systems, inhibiting the potential role technology could have as an effective safety control.
- Impact of patients moving around department – one patient could be seen by different clinical staff across one department. This increases the frequency of checks and the chance that the patient is misidentified at some point.
The report concludes with one safety recommendation which focuses on reviewing the risks, identifying the most effective systems to reduce risks, and assessing the feasibility of these systems for implementation.
Dr Sean Weaver, Deputy Medical Director at HSIB says: “Any invasive procedure carried out incorrectly has the potential to lead to serious physical and psychological harm and erode trust in the NHS. In our case, the patient told us she was so distressed after the incident that she did not want to pursue her fertility treatment.
“It was important to explore this patient safety risk at the system level, especially as invasive procedures being done in outpatient settings continue to increase, even without any changes that might be brought about due to the Covid pandemic.
“Like many of our recent investigations focused on Never Events, this report emphasises the current barriers in place to prevent these incidents are not strong or systemic. We have set out detailed analysis and learning for those working in outpatient settings across the NHS. The safety recommendation we have made is there to encourage cohesive and effective changes at a national level, to reduce the risk of misidentification, and ensure the right patient receives the right procedure.”