Local integrated investigation pilot 2: Incorrect patient details on handover
HSIB Legacy
Published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
6 recommendations
4 observations
5 of 6 responded
Safety Recommendations (6)
Anonymous
R/2022/170
HSIB recommends that the nursing home implements a mechanism to use care records with the lowest risk of having incorrect personal identification data during interactions with the wider healthcare system.
The nursing home reviewed local systems, introduced pre-admission checks with GPs, implemented regular audits, and created a new hospital transfer pack to improve patient identification data accuracy.
The nursing home responded to this safety recommendation and described their following actions: Review of local systems around documentation of personal identification data that is shared with other organisations. Introduction of additional measures including checking of pre-admission information with a patient’s respective GP. Weekly and monthly audits of all documentation containing personal details. A new hospital transfer pack to ensure accurate personal information is passed on to an ambulance crew. Response received on 10 May 2022.
Anonymous
R/2022/171
HSIB recommends that the Ambulance Trust carries out additional personal identification data verification when a successful Patient Demographic Service search via NHS Spine has not been achieved.
The Ambulance Trust updated its protocols to include obtaining a full Patient Demographic Service match and double-checking details for additional verification when PDS search is unsuccessful.
The Ambulance Trust responded to this safety recommendation and described their action to include ‘Obtain FULL PDS Match and double check details are correct’ into their protocols. Response received on 2 March 2022.
Anonymous
R/2022/172
HSIB recommends that the Acute Trust, in collaboration with the Ambulance Trust, develops and implements a formal emergency department booking-in policy.
The Acute Trust has committed to developing a formal emergency department booking-in policy in collaboration with the Ambulance Trust.
The Acute Trust responded to this safety recommendation and described their action to develop a booking-in policy in collaboration with the Ambulance Trust. Response received on 19 April 2022.
Anonymous
R/2022/173
HSIB recommends that the Acute Trust carries out additional personal identification data verification when an NHS number is not available.
The Acute Trust is reviewing its Positive Identification of Patients Policy, specifically focusing on additional verification when an NHS number is unavailable.
The Acute Trust responded to this safety recommendation and described their action to review their Positive Identification of Patients Policy in relation to the HSIB investigation report and findings, with particular focus on when an NHS number is not available. Response received on 19 April 2022.
Anonymous
R/2022/174
HSIB recommends that the Acute Trust tests its positive patient identification procedure for patients with dementia in order to identify risks and support the development of effective mitigating controls.
The Trust held an FMEA workshop to test its patient identification procedure for dementia patients, which yielded internal recommendations for risk mitigation.
A Failure Modes and Effects Analysis (FMEA) workshop was held by the Trust in respect of their positive patient identification procedure. The workshop resulted in a number of internal recommendations to mitigate the risks highlighted within the HSIB report. Response received on 19 April 2022 and updated 18 November 2022.
R/2021/131
HSIB recommends that NHS England and NHS Improvement leads a review of risks relating to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise. This should assess the feasibility to enhance or implement layers of systemic controls to manage these risks. It should also consider existing challenges relating to the usability and practice of including the NHS unique identifier in patient identification procedures and consider technological solutions to support its use.
Safety Observations (4)
It may be beneficial if the Acute Trust reviews the infrastructure and layout of the emergency department majors area in order to support the flow co-ordinator to reliably carry out their full responsibilities.
It may be beneficial if the Acute Trust considers the results of current research to understand whether a way of visually identifying patients with dementia would be appropriate to help positive patient identification.
HSIB notes the following specific national safety risk
The NHS number is a unique identifier for people living in England (and Wales). There is a risk to the accurate identification of patients when the NHS number is not used as the primary patient identifier.
It would be beneficial if it was easier for trusts to find clear national guidance on what a good patient identification check looks like to assist the quality and consistency of trust guidance.
It would be beneficial if there was national guidance on the principles for good design of tools to support the critical task of patient identification.