Patient Identification

Patient misidentification is increasingly being recognised as a widespread problem within healthcare organisations. The National Patient Safety Agency (NPSA) has recognised patient misidentification as a significant risk within the NHS and one, which needs urgent attention. Over a 12-month period February 2006 – January 2007 the NPSA received 24,385 reports of patients being mismatched to their care. It is estimated that more than 2,900 of these related to ID bands and their use.

The SHOT (Serious Hazards of Transfusion) Annual Report 2005 identified ‘incorrect blood component transfused’ as the most frequently reported incident related to blood transfusion. Data over 9 years shows that 71.5% of reported blood transfusion incidents involved transfusion of the wrong blood to patients. The outcome of this included the death of 22 patients and major morbidity e.g. conditions requiring ICU admission.

The extent to which patient misidentification happens is widely underestimated by clinical staff, as very often they are unaware that a misidentification has occurred. Patient misidentification can lead to all sorts of serious outcomes and treatment delays for patients. The following types of incidents have been reported:

• • Administration of the wrong blood/drug to the wrong patient
  • Performing a wrong procedure on a patient
  • Mislabelling of a specimen which subsequently gives an abnormal result can then result in the inability to trace the patient to whom the original specimen relates, resulting in treatment delays
  • Patient is given the wrong diagnosis
  • Patient receives inappropriate treatment e.g. incorrect blood component
  • Patient is over-exposed to radiation
  • Wrong patient is brought to Theatre
  • Mother is given wrong baby
  • Cancellation of operations due to the misfiling of results, GP letters and correspondence

Clinical incidents and near misses must be reported via NHS Lothian’s Incident Reporting Procedure. Ensuring correct patient identification poses a challenge in hospitals because of the number of complex interventions that occur to patients, ranging from drug administration, phlebotomy to complicated invasive procedures.

Regardless of the healthcare setting a patient’s identity should be confirmed prior to commencement of any treatment / therapy or administration of medication. It is equally important to do so even in a patient’s own home.

It is acknowledged and accepted that in many outpatient, community settings and Adult Mental Health inpatient wards it is not appropriate to use patient identity bands. However, specific local procedures must be in place to ensure patient safety.