http://www.npsa.nhs.uk/site/media/documents/1246_PSO_Report_FINAL.pdf
Misidentification of patients is a theme that occurs in any analysis of
patient safety. The
NPSA has already released an alert on correct site surgery to address
one specific area of this
source of harm to patients. The NPSA is also working on other areas
which are related to
misidentification such as ensuring compliance with wristband wearing in
acute services and
reducing incidents of incompatible blood transfusions.
The NPSA believes that there is considerable scope in the NHS for
improving patient safety,
both through the development of fail-safe methods of manual
identification and checking and
through applying technologies such as barcodes, radio frequency
identification and biometrics.
A search and analysis of the NRLS data to identify incidents of
mismatching showed that:
• 493 reports of mismatching were found from 45 reporting trusts;
• two-thirds of these reports were from medical, surgical and
diagnostic specialties in
acute hospitals;
• one in every eight incidents specifically related to issues with
identification of patients with
wristbands, and half of these were due to a missing wristband;
• of 32 incidents where the wristband was missing, three led to
patients having
unnecessary x-rays;
• two patients with missing wristbands received treatment intended for
another patient
(one a blood transfusion, one an antibiotic);
• four out of ten reports included discrepancies with information on
the wristbands or where
the information on the wristband differed from other relevant documents;
• of these 26 incidents, there were 22 occasions when the information
on patients’ wristbands
was incorrect and the staff involved would therefore not proceed with
the treatment until
they could confirm the patients’ identity;
• in eight of these cases, a patient had been transferred to theatre
before the error
was discovered.
The data have confirmed that there is a lack of a systematic and
standardised process to
support the identification of patients in a way that allows healthcare
staff to match them to
their care, treatment and records. This work will inform further advice
for the NHS scheduled
for autumn 2005, and additional work to produce a standard for patient
identification.
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