Positive patient identification
Published
Communication and decision making
Checking
We've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and identifies how these misidentifications have been able to happen.
1 recommendation
5 observations
2 actions
1 of 1 responded
Safety Recommendations (1)
NHS England
R/2023/215
HSSIB recommends that NHS England assesses the priority, feasibility and impact of future research to quantify and qualify the risk of patient misidentification. This is to support future prioritisation of work programmes to improve safety in high-risk situations and settings.
NHS England has assessed the evidence, developed a policy research request for patient misidentification, secured approval from its RNP, and received prioritisation from DHSC. Discussions are ongoing with NIHR regarding research scope.
NHS England’s National Patient Safety Team conducted an initial assessment of the evidence base, to determine what is already known about this issue and engaged with a wide range of stakeholders with a broad range of knowledge, skills and expertise to develop research question(s) to address the evidence gap that was highlighted in HSSIB’s report. A previously published HSSIB report identified safety risks from patient misidentification and limited access to critical information at the bedside. One of the safety recommendations (HSIB safety recommendation R/2023/215) was that NHS England assesses the priority, feasibility, and impact of future research into what and how critical information pertaining to the emergency care of patients in the acute hospital setting can be readily and reliably accessed at a patient’s bedside. The team identified a strong link between positive identification and access to accurate critical patient information. Therefore, it was pragmatic to address both issues in a single research request. Subsequently the team developed and submitted a request for policy research for the two safety recommendations (i.e. R/2024/017 – Positive Patient Identification AND R/2023/215 - Access to critical patient information at the bedside) to NHS England’s Research Needs Panel (RNP) in July 2023. The RNP is NHS England’s in-house process to review, agree and prioritise policy research needs for formal submission to the Department of Health and Social Care's Research and Development Committee. The panel is made up of representatives from all directorates of NHS England. The RNP subsequently approved the request and so formal submission of the research request was made to the Department of Health and Social Care’s Research and Development Committee. The request was prioritised by that committee in October 2023. Discussions are now (March 2024) ongoing with the National Institute of Health and Care Research (NIHR) to agree the research scope and the potential commissioning routes. Response received on 14 March 2024.
Safety Observations (5)
Future improvement programmes considering the risk of patient misidentification can improve patient safety by prioritising high-risk situations and settings, such as handovers and transfers of patient care. Multiple controls may need to be introduced, including new technologies and standardising of processes.
Healthcare organisations can improve patient safety through the use of principles of ‘user-centred design’ to help them understand and optimise clinical work settings for positive patient identification.
Those designing patient identification processes, including related software, can improve patient safety by undertaking effective equality impact assessments and by considering the needs of specific patient groups that are at high risk of being misidentified.
Those purchasing and implementing electronic patient record systems in healthcare organisations can improve patient safety by ensuring those systems are compliant with relevant risk management standards (such as DCB0129, DCB0160 and DCB1077).
Healthcare services can improve patient safety by seeking to better understand and address the risks associated with positive patient identification through a safety management system approach.
Safety Actions (2)
HSSIB suggests that integrated care boards assure processes for the transfer of patient care between healthcare organisations in their geographical footprints to reduce variation in processes for patient identification.
HSSIB suggests that integrated care boards assure that where a patient misidentification has occurred, healthcare organisations in their geographical footprints have collaborative processes to learn why and to ensure health records are correctly allocated.