Response to HSIB investigation: Incorrect patient identification


  • 25th November 2021

Today the Healthcare Safety Investigation Branch (HSIB) has released a new report investigating a patient identification error. This forms part of a local pilot, which has been launched to evaluate HSIB’s ability to carry out effective investigations occurring between specific hospitals and trusts.

The investigation reviewed the case of a woman who was taken to an emergency department by ambulance in April 2021, following a 999 call from her Granddaughter to the emergency operations centre. The emergency operations centre used the wrong NHS number for the patient, which was assigned to her for the duration of her stay in hospital and led to her being advised to take incorrect medication.

Patient Safety Learning welcomes the publication of this report and HSIB exploring new approaches to their patient safety investigations through this pilot programme. Our reflections on this report are as follows:

Wider value of these findings

In their report HSIB make four recommendations relating to the Acute Trust and Ambulance Trust in this case. It may be that there are similar issues occurring in other trusts across the country and that there would be value in NHS England and NHS Improvement reviewing patient identification processes more broadly in line with these findings. We would also suggest it would be helpful if NHS England and NHS Improvement could identify examples of patient identification good practice that could be shared more widely.

Role of patient and family engagement

HSIB states in its report that the patient, when offered the incorrect medication, declined this, but for unclear reasons. It also notes the role played by the patient’s Granddaughter in identifying this error on two separate occasions:

  • On the first day she alerted staff to incorrect information on the patient’s wristband, but no record was made of this.
  • On the fifth day she alerted staff to an error regarding her grandmother’s details on medical records.

It is notable however that the error was not formally addressed until the pharmacist noticed a discrepancy and confirmed this was an error when speaking to the patient’s Granddaughter. We believe this serves to underline the importance of engaging and listening to patients and their family members. This patient safety issue may have been identified and addressed much more swiftly if the patients Granddaughter’s concerns about incorrect patient information had been followed up on appropriately.

Response to HSIB investigation


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