The national learning report draws together evidence from six completed Healthcare Safety Investigation Branch (HSIB) investigations and wider intelligence, such as the research literature and national policy documents. The aim of the report is to support national learning and influence national action to reduce the risk of patient misidentification.
Our report emphasises that misidentification can lead to significant harm, citing examples from the six HSIB investigations.
- a patient who received an invasive procedure not meant for them
- a patient who bled after receiving anticoagulation medication not meant for them
- a patient who did not undergo a resuscitation attempt because it was thought he was a different patient.
The report also outlines a new patient story. Whilst we did not investigate the case, we did speak to the wife who described how her husband had been misidentified several times over a number of years whilst undergoing treatment for bladder cancer and then a brain tumour.
Sharing learning and understanding the risk
The report notes that patient misidentification was highlighted as a risk to patient safety by the National Patient Safety Agency in the early 2000s. However, one of our key findings in the report is that misidentification is challenging to address and previous efforts to reduce the risk have not been as successful as hoped.
The secondary analysis of HSIB’s six reports ‘identified a complicated array of interacting factors in different healthcare systems that contributed to misidentifying patients.’
Some of the factors have been expressed in our key findings which include:
- Positive patient identification is seen as a routine task, but is common, complex and critical for patient safety. It relies on staff following instructions described in policies and procedures, which might not always be fully appropriate to the circumstances within which staff are identifying patients.
- The main control in preventing patient misidentification in England is the NHS number. However, there is sometimes no, varied or limited use of the NHS number in clinical practice due to various factors.
After reviewing the safety recommendations and safety observations in the investigations, our report concludes that it is not yet possible to eliminate the risk of patient misidentification but that a series of safety interventions may help to reduce the risk.
The research literature we reviewed described the opportunities for the increased use of technology. Our report notes that any effective solutions could involve technology, however we also emphasise that technology alone is unlikely to reduce the risk. Work systems involving people, technology and tools need to be designed to improve identification processes.
Reducing the risk
Whilst our national learning report identified that current controls are unable to prevent all misidentifications, there are opportunities to better support staff by improving working conditions, particularly in situations and settings when there is a higher risk. The report gives the examples of handovers and transfers of care.
We also identified that designs of current software and identification processes may be disadvantaging some patient groups (for example, patients with a disability or of certain cultural backgrounds) due to limited consideration of their needs.
Our report identified all the above issues but also that improvement is challenging as the risk is underestimated, even though our investigations showed it can lead to significant harm. In the report we state that ‘under-recognition of the risk is preventing allocation of already limited safety resources to further mitigate the risk. In response to our findings, we have made three safety recommendations, one of which is focused on NHS England assessing the priority, feasibility and impact of future research to quantify and qualify the risk.
Nick Woodier, Senior Safety Investigator at the Health Services Safety Investigations Body, says: “The six HSIB investigations considered misidentification across different areas of NHS care – from outpatient procedures and emergency departments to ambulance services and care homes.
“The evidence we have collected aligns with research literature and data from national incident databases and emphasises that despite national improvement efforts, misidentification remains a persistent safety risk. Our report offers insight into where effective solutions could be implemented but we recognise that there is difficulty in allocating resources when healthcare organisations tell us that the scale of the problem is not known.”
“Our investigations gave some stark examples of the impact on patients, and in the new story, how misidentification can lead to distress and frustration. This is why our safety recommendations and findings are aimed at influencing national action to better understand the risk and consider how resources can be allocated to drive improvement across England.”
- Several studies in the research literature have considered the risk of misidentification. For example, one study reported that misidentifications accounted for around 70% of adverse outcomes, including reactions to wrong blood, unnecessary surgery and delayed cancer diagnoses (Dunn and Moga, 2010). Another study reported that adverse events resulted from one in every 18 misidentifications in a laboratory (Valenstein et al, 2006), while another found that up to 20% of misidentifications in laboratories translate into harm (Lippi et al, 2017).
- An investigation of around 8000 wrong-patient events between 2013 and 2015 included events that resulted in patient deaths (Emergency Care Research Institute, 2016).
- A review of the Strategic Executive Information System (StEIS) for incidents relating to misidentification found 171 reported as occurring between 1 April 2017 and 1 January 2023. These are ‘serious incidents’ that have resulted in actual or potential significant harm to patients.