This national learning report (NLR) draws on findings from investigation reports completed by the Healthcare Safety Investigation Branch (HSIB) that considered the risks associated with patient identification. ‘Positive patient identification’ is correctly identifying a patient to ensure that the right person receives their intended care. To support patient identification in England, the patient’s NHS number should be used alongside other identifiers, such as their name, date of birth and address.
Patient misidentification is where a patient is identified as someone else. This may mean that a patient does not receive the care meant for them, or that they receive the care meant for someone else. Patient misidentification was highlighted as a risk to patient safety by the National Patient Safety Agency in the early 2000s. Despite the time that has passed, patient misidentification remains a persistent risk to patient safety that can result in significant harm.
The aim of this NLR was to combine and analyse HSIB’s previous investigations and relevant international research literature, with the goal of informing national learning and influencing national actions to help reduce the risk of patient misidentification.
This NLR has used the following approaches and has combined the findings to make safety recommendations and safety observations.
- Secondary analysis: six previous HSIB investigation reports were analysed to identify themes around the factors that lead to patient misidentification.
- Review of HSIB’s safety interventions: safety recommendations and safety observations from the HSIB investigation reports were categorised to explore how they aimed to reduce the risk of patient misidentification.
- Review of the literature: 12 review articles around new and developing opportunities to reduce the risk of patient misidentification were identified and their findings collated.