A member of care home staff walks around a garden with their arm around the shoulders of an older person.

Report examines case of incorrect patient details during handover of care between local healthcare organisations

by Communications team

The second report from our local integrated investigation pilot focuses on the impact of incorrect patient details during handover of care.

We investigated a safety event involving Mrs E, a 93 year old woman with dementia who, after a fall in her nursing home, was taken by ambulance to her local emergency department (ED).

An incorrect spelling of surname and incorrect date of birth had been recorded by the Ambulance Trust. As a result, ED staff could not find Mrs E using available digital patient management systems when they tried to book her in and a new patient record was created with incorrect personal details.

Mrs E had an X-ray which confirmed there was no fracture and she was discharged the same day. The next day, she had another fall and was transferred back to the same ED where she was booked in again with the incorrect personal details.

She was admitted to hospital this time as she needed surgery for a hip fracture. The error with Mrs E’s personal details was eventually identified by the pathology department while surgery was taking place.

Investigating communication points as safety risks

The investigation examined the key communication points in Mrs E’s care and identified where safety risks emerged in the information handover between the nursing home, the Ambulance Trust and Acute Trust.

The report sets out 14 findings relating to areas such as verification of personal identification data, the impact of ‘emergency rules apply’ procedures, the use of digital systems and their search functionality, inconsistency in booking-in procedures in ED, the Acute Trust’s use of the NHS number and considerations for patients with dementia – positive patient identification and the use of patient identification bands. The findings formed the basis of the five safety recommendations and two observations directed to the healthcare organisations for action.

As with our first local trial investigation, we also identified three points for national learning. These focused on the heavy reliance on staff checking to ensure information is correct, the variation of pathways and procedures across different trusts and the inconsistent use of the NHS number as a unique patient identifier. The report reiterates that there is a national safety risk attached to not using the NHS number as the primary identifier for patients.

Craig Hadley, Lead Investigator at HSIB says “Incorrect patient details at handover of care cause confusion, delays and in the most serious of circumstances could lead to unsafe treatment being administered, causing further harm to the patient.

“It was important that we examined the systems and procedures the healthcare organisations had in place to understand where safety risks were most likely to emerge in the positive identification of patients, especially when dealing with patients who have more complex needs. We have worked closely with staff at both Trusts and the nursing home and formulated recommendations that will enable them to address the specific safety risks and reduce the likelihood of this type of incident happening again.

“The findings from the local incident as well the national points of learning will provide insight for anyone dealing with patient information systems in health and social care across England.”

The local pilot project 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.

The first report of three in the pilot was published in December 2021. The reports, along with 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.

Back to news

Related news

An image of the Houses of Parliament, Westminster, London

HSIB welcomes Royal Assent of Health and Care Act

Read news article
Older male man lies on a bed with his worried wife sitting with him, holding his hand.

Report examines unintentional overdose of powerful medication used for pain relief

Read news article
Image of birth parent and newborn baby

BAPM Webinar: Sudden Unexpected Postnatal Collapse

Read news article
A Black mother cradles her newborn baby who is asleep in her arms.

Ockenden report

Read news article
An ambulance parked outside a hospital

Investigation highlights challenges when diagnosing ‘time-critical’ pulmonary embolism in the emergency department

Read news article