Hospitals harm hundreds of patients a year by misidentification

Hundreds of patients are being harmed each year because NHS organisations have incorrectly identified who they are, an HSJ investigation has found.

Responses to Freedom of Information requests from 166 trusts revealed 58,537 cases of patient misidentification logged in Datix or other patient safety systems between 2019 and 2023, including 4,713 causing some sort of harm. This is equivalent to 11,707 incidents a year, with 943 leading to harm.

It includes a wide range of errors, but harm typically happens when patients are given the wrong treatment or medicine, or miss out on the right treatment, as a result of errors in recording and/or miscommunication. A typical example is patients being given a wristband with the wrong name – or ID information resulting in patients not being treated, or the wrong treatment being given.

Some of the worst examples are where the wrong patient, or the wrong part of the body, is operated on.

Patient Safety Learning's CEO Helen Hughes called on NHS England to review cases nationally to identify root causes.

She added: “Where avoidable harm has occurred, it is vital these incidents are investigated, that causes and contributory factors are identified, and steps put in place to prevent their reoccurrence. In some cases, this may require standardisation of approaches to patient identification, while others may highlight contributory factors that are more difficult to address, such as staff fatigue.”

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Source: HSJ, 11 June 2024