National learning report

Positive patient identification

Date Published:

Theme:

  • Communication and decision making,
  • Checking

A note of acknowledgement

We would like to thank the many patients, families and staff who shared their experiences for each of the investigations that contributed to this national learning report. This report also describes a referral received by the Healthcare Safety Investigation Branch (HSIB) about the misidentification of a patient (see section 2). HSIB did not investigate the events affecting the patient, but his family’s experiences are described. We are grateful to the patient’s wife for sharing their experiences.

About this report

This is a legacy ‘national learning report’ completed by the Health Services Safety Investigations Body (HSSIB) under the National Health Service Trust Development Authority (Healthcare Safety Investigation Branch) Directions 2016. It draws together evidence from completed HSIB investigations and wider intelligence, such as the research literature and national policy documents. By combining this evidence, HSSIB has been able to consider more widely the factors that contribute to patients being misidentified within the healthcare system. In addition, bringing together multiple forms of evidence supports the safety recommendations and safety observations made in this report.

This report is aimed at healthcare organisations and policymakers to help improve patient safety in relation to patient identification. While safety recommendations are made to national healthcare bodies, the safety recommendations, safety observations and findings may also be applicable to the wider health and care sector, including integrated care boards.

Temporary identification of unknown/unidentified or refused to be known patients (NHS Improvement, 2018a) had not been considered in the previous HSIB investigations and so was not within the scope of this national learning report.

Executive summary

Background

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.

Aim and approach

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.

Findings

  • Patient misidentification is challenging to address and previous efforts to reduce the risk have not been as successful as hoped. There may be a benefit in proactively ensuring that processes for identifying patients are safe, rather than reacting to incidents of harm.
  • 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.
  • Patients are at higher risk of being misidentified in certain situations and settings. Examples include handovers and when care is transferred between different healthcare organisations.
  • The risk of patient misidentification is underestimated and patient misidentification can result in significant harm to patients. Under-recognition of the risk is preventing allocation of already limited safety resources to further mitigate the risk.
  • 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.
  • Technology alone is unlikely to reduce the risk of patient misidentification. Work systems involving people, technology and tools need to be designed to improve identification processes.
  • The 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.
  • It is not yet possible to eliminate the risk of patient misidentification. However, a series of interventions – including using new technologies and optimising workplaces – may help to reduce the risk.
  • When a patient is misidentified, it is difficult to correct the misidentification and ensure their records are made accurate.

HSSIB makes the following safety recommendations

Safety recommendation R/2024/017:

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.

Safety recommendation R/2024/018:

HSSIB recommends that the Care Quality Commission develops its methodology for assessment of integrated care systems and organisations to include arrangements for the positive identification of patients at transfer between healthcare organisations. This is to reduce variability in processes and what information is used for identification.

Safety recommendation R/2024/019:

HSSIB recommends that NHS England reviews and identifies system-wide requirements for scanning in positive patient identification. This is to support local organisations to use scanning technology to reduce misidentification incidents.

HSSIB makes the following safety observations

Safety observation O/2024/013:

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.

Safety observation O/2024/014:

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.

Safety observation O/2024/015:

Healthcare organisations can improve patient safety by assessing and addressing their local barriers to using the NHS number for patient identification.

Safety observation O/2024/016:

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.

Safety observation O/2024/017:

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).

Safety observation O/2024/018:

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.

HSSIB suggests the following safety actions for integrated care boards

Suggested safety action ICB/2024/004:

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.

Suggested safety action ICB/2024/005:

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.

1. Background and context

This national learning report (NLR) explores the positive identification of patients and the risk of patient misidentification. This section provides relevant background to this NLR and describes the reasons for its publication.

1.1 Positive patient identification

1.1.1 ‘Positive patient identification’ is correctly identifying a patient to ensure that the right patient receives their intended care. Care may include tests for diagnosing health problems and routine or emergency treatments.

1.1.2 Patient identification is a process undertaken every time a patient is in contact with healthcare staff. This means it is a frequent necessity to identify patients, sometimes over long periods of care. The process involves an initial identification of the patient, and then repeated verifications of their identity as care progresses. For each identification and verification, national bodies and local organisations describe the steps required in policy documents, such as in figure 1.

1.1.3 To support identification, the patient’s NHS number should be used as a unique identifier (National Patient Safety Agency, 2009), alongside other identifiers such as the person’s name, date of birth and address. In some healthcare settings, patients will be given an identity wristband with information including their name, date of birth and NHS number.

Figure 1 Example process for patient identification where a patient does not have a wristband (adapted from, Healthcare Safety Investigation Branch, 2021a)

Image of figure 1 showing an example process for patient identification with the key 3 elements of 'Ask' 'Check' and 'Confirm' stages.

NHS number

1.1.4 The NHS number is a 10-digit number that is unique to a person. It is assigned at birth or the first time a person receives NHS care in England. The number is also used in Wales and the Isle of Man. The number remains with the person for life, but a new number may be assigned for reasons such as adoption or gender reassignment (NHS, 2019).

1.1.5 An NHS number is documented on most NHS documents that are specific to a person, such as prescriptions, test results and appointment letters. A person can also find their NHS number using the NHS App (NHS, n.d.a) and through the NHS’s online services (NHS, n.d.b).

1.2 Misidentification of patients

1.2.1 ‘Patient misidentification’ is where a patient is identified as someone else. Misidentifications can result in a patient not receiving the care meant for them, or receiving the care meant for someone else. Patient misidentification has long been recognised as a safety risk in the NHS (National Patient Safety Agency, 2004) and is a persistent issue internationally (Emergency Care Research Institute, 2022).

1.2.2 In England, guidance and national alerts published between 2004 and 2018 have encouraged healthcare organisations to consider their processes for reducing the risk of patient misidentification (see table 1). The guidance includes mandating the use of the NHS number to identify patients. However, cases of misidentification continue to occur.

Table 1 Guidance and national alerts around the misidentification of patients published 2004 to 2018

Source Title Contents
National Patient Safety Agency, 2004 Right patient – right care Framework for action – ‘… the use of technology to prevent mismatching is both desirable and achievable.’
National Patient Safety Agency, 2005 Safer practice notice: wristbands for hospital inpatients improves safety ‘All hospital inpatients in acute settings should wear wristbands (also known as identity bands)…’
National Patient Safety Agency, 2007 Safer practice notice: standardising wristbands improves patient safety ‘… sets out the action to be taken by the NHS to ensure wristbands are standardised.’ Identifiers include last name, first name, date of birth and NHS number.
National Patient Safety Agency, 2009 Safer practice notice: risk to patient safety of not using the NHS number as the national identifier for all patients ‘Use the NHS Number as the national patient identifier; OR the NHS Number as the national patient identifier in conjunction with a local hospital numbering system.’
NHS Improvement, 2018b Recommendations from National Patient Safety Agency alerts that remain relevant to the never events list 2018 Following archiving of the National Patient Safety Agency website, this document provides an overview of historical alerts still relevant to prevent never events.

Risk of patient misidentification

1.2.3 HSIB received several referrals relating to patient misidentification (for an example, see section 2). HSIB also undertook investigations into patient misidentifications, as outlined in appendix 6.1.

1.2.4 HSIB’s previous investigations showed the actual and potential harms that can result from a patient being misidentified, such as a patient undergoing a procedure not meant for them (Healthcare Safety Investigation Branch, 2021a). Other national publications have also highlighted the harms that can occur (for example, Serious Hazards of Transfusion, 2021). Patients have suffered and continue to suffer significant physical and psychological harm as a result of being misidentified as someone else.

1.2.5 While the potential for harm from patient misidentification is recognised, the likelihood of it occurring – and therefore the risk to patients – is underestimated by healthcare services (Ferguson et al, 2019). The reasons the risk is underestimated include: under-reporting of safety events; reporting of misidentifications as something else, such as ‘medication administration incidents’; and limited understanding about why misidentifications occur (Bártlová et al, 2015; Ferguson et al, 2019; Levin et al, 2012). In addition, the risk to patients will vary depending on the healthcare settings and situation within which identification is undertaken. Two HSIB investigations found that patient misidentification was a hidden risk in the organisations involved, the extent of which was unknown (Healthcare Safety Investigation Branch, 2021b, 2022).

1.2.6 It is difficult to evaluate the risk of patient misidentification as there is no single comprehensive source of information, and not all misidentifications are reported. However, during the development of this NLR, HSSIB identified the following:

  • 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).
  • Policy publications include examples exploring the risks of patient misidentification, including that misidentification during transfusion is a challenge and causes harm (Bolton-Maggs et al, 2013). 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.
  • Several HSIB maternity investigations involved misidentifications of women and babies. These included misidentifications while using software and other technologies, and when labelling samples such as blood and urine.

1.3 Decision to launch this NLR

1.3.1 HSIB investigations showed that patient misidentification occurs in different healthcare settings and that the likelihood of it occurring may be greater than recognised. HSIB undertook four national investigations (Healthcare Safety Investigation Branch, 2019, 2020, 2021a, 2023) and two local investigations (Healthcare Safety Investigation Branch, 2021b, 2022) that considered events where a patient was misidentified appendix 6.2.

1.3.2 The investigations identified factors that contributed to misidentifying patients across different healthcare settings and situations. It was proposed that the findings should be combined for national learning and the development of safety recommendations. As the proposal met HSSIB’s criteria for the launch of an NLR (see appendix 6.1), the Chief Investigator authorised this publication.

Aim of this report

1.3.3 The approach taken to develop this NLR is described in appendix 6.1. This NLR combined and analysed previous HSIB investigations and relevant international research literature, with the goal of informing national learning and influencing national actions to help reduce the future risk of patient misidentification.

2. Secondary analysis of HSIB investigations

This section describes the findings of HSSIB’s secondary analysis of HSIB’s relevant investigations (see appendix 6.2). Coding was based around the Systems Engineering Initiative for Patient Safety (Holden et al, 2013). Investigation reports and quotes from the reports are cited in this section, and the coding is available in appendix 6.3.

HSIB also received several other referrals related to the risk of patient misidentification that have not been included in this analysis. One such referral is shared in box 1. HSIB did not investigate the referral, but heard about the events from the patient’s wife.

Box 1 HSIB referral of a patient misidentification, based on a narrative from the patient’s wife

The patient was a fit, healthy and active person. His wife described him as someone who would “follow his heart”. He was creative and artistic, and had a particular interest in vintage cars that he shared with his son.

The patient was diagnosed with bladder cancer in 2014. He received surgery and follow-up at hospital 1. Follow-up involved scans and cystoscopies (where a thin camera is used to view the inside of the bladder). The patient and his wife were first suspicious of a misidentification in 2017 when the patient arrived at hospital 1 for a cystoscopy. He was told that the cystoscopy had been cancelled because he “had just had one”. The patient’s wife recalled that staff had remarked there were two people with the same name, one being her husband. Following confirmation that the patient had not received a cystoscopy, it was rebooked and undertaken. Similar misidentifications were thought to have occurred on at least two further occasions.

In 2020 the patient was diagnosed with a brain tumour. He was transferred to hospital 2 for surgery. There were several times when the patient’s wife believed that staff had confused her husband with another patient. This was apparent to her through discussions with staff around his previous diagnoses and medication which were inaccurate.

On several occasions, the patient’s wife expressed her concern that her husband’s medical records had become mixed up with those of another person. The patient had a common name, particularly in the area where he lived. She described how that, without their suspicions and persistence, her husband would not have received the care he required.

The events caused significant “frustration” and the patient’s wife did not feel listened to, despite raising her concerns with her husband’s GP, hospital 1 and hospital 2. This led to a lack of trust in the information contained in the patient’s medical records and in communications received by his wife. Following the patient’s later death, his wife continued to be concerned about potential misidentification as she had received limited assurance that inconsistencies in the medical records had been addressed. Because of the potential risk to other patients, HSIB raised concerns with the relevant organisations, which identified no ongoing safety concerns.

2.1 Initial misidentification of a patient

2.1.1 The HSIB investigations included in this report considered events in a variety of inpatient and outpatient settings. In each, there was an initial misidentification of a patient and then ongoing misidentifications when the patient’s identification was verified.

2.1.2 The term ‘initial misidentification’ relates to the first point at which a patient is misidentified as someone else. In the investigations, these misidentifications occurred when the patient was initially admitted to hospital or transferred between organisations, or when tests or administrative tasks were undertaken. Processes to identify patients were found to vary between individual healthcare providers and were inconsistently followed. Staff knew of the existence of local processes, but in some cases the local processes could not be followed as they were written, and so were adapted by staff as needed.

2.1.3 The following paragraphs describe the interactions between staff and their surrounding work systems, and how this affected patient identification.

Local policy and workload

2.1.4 Factors that contributed to patient misidentifications included local policies and their implementation, a high workload, demand on services, and limited management of safety risks.

2.1.5 Local policies varied in their descriptions of how patient identification should be undertaken – for example, what identifiers should be used and the role of the NHS number.

‘The Trust’s patient identification policy did not include use of the patient’s NHS number.’ Healthcare Safety Investigation Branch, 2021b

2.1.6 Policies did not always consider the complexity of the identification process or guide staff on how to deal with particular circumstances. For example, there was limited direction on what to do when two patients on a ward had a similar name (Healthcare Safety Investigation Branch, 2023).

2.1.7 Staff were not supported to ensure they had knowledge of local identification policies.

‘… it was “assumed” that [staff] would know what to do, and any patient identification training was part of “packages” such as medication administration.’ Healthcare Safety Investigation Branch, 2023

2.1.8 There was also limited awareness of the ability of electronic systems to support patient identification, such as where systems matched patients to records and ‘flagged’ patients with similar names (Healthcare Safety Investigation Branch, 2022, 2023). Staff were not educated on these elements when they were trained on these systems.

2.1.9 Increasing workloads led to staff attempting to be more efficient (Healthcare Safety Investigation Branch, 2021a, 2022). This was found to reduce thoroughness – known as the efficiency–thoroughness trade-off (Hollnagel, 2009). There was also an example of where procedures called for reduced thoroughness when the clinical workload was increasing.

‘… at the time of the safety event, because of the number of 999 calls waiting, the Ambulance Trust [emergency operations centre] was using “emergency rules apply” procedures [where 999 call handlers did not need to obtain patients’ names for ambulance crews].’ Healthcare Safety Investigation Branch, 2022

2.1.10 Some organisations knew that the demand on their services had been increasing over time, but there was limited evidence that the organisations had made plans to mitigate the associated potential risks (Healthcare Safety Investigation Branch, 2021a). This was found to be contributed to by under-recognition of the associated risks and limited understanding of the implications.

Local working conditions

2.1.11 The design of the environments within which staff worked and the technologies used were found to contribute to patient misidentification.

2.1.12 ‘The environment’ refers to the physical workspace in which staff undertake patient identification. The design of workspaces had introduced challenges that led to variations in how healthcare workers undertook patient identification. Examples included the visibility of patient information at the bedside (Healthcare Safety Investigation Branch, 2023) and the risk of mixing up information at workstations.

‘… there was a period when nursing and pharmacy records were stored loosely on the nurses’ station and in the red medical record folder, where additional paperwork could easily become attached.’ Healthcare Safety Investigation Branch, 2020

2.1.13 The layout of workspaces was found to affect the space at bedsides for safety-critical tasks, such as labelling blood samples (Healthcare Safety Investigation Branch, 2019). There was also evidence of distractions and interruptions (Healthcare Safety Investigation Branch, 2020).

2.1.14 ‘Technology’ refers to the hardware, software and paper documentation used by staff. Accessibility, availability, usability and functionality issues with software and hardware were found to limit their role in supporting patient identification. Problems with the information displayed on user interfaces were noted.

‘The risk of misidentification within IT systems is influenced by the design of the user interface and how or which information is presented at any one time to support identification.’ Healthcare Safety Investigation Branch, 2021a

2.1.15 Few of the software systems examined offered alerts, prompts or forced stops to minimise the entry of incorrect patient information (Healthcare Safety Investigation Branch, 2022, 2023). Staff were also found to face challenges when accessing software because of limited availability of computers or handheld devices, limited battery life and log-in problems (Healthcare Safety Investigation Branch, 2019, 2023).

2.1.16 The interoperability of technology was also an issue. Software systems did not always communicate in ways that ensured consistent, accurate information was available across systems (Healthcare Safety Investigation Branch, 2021b). The risk of patient misidentification was also increased when paper and digital systems were used alongside each other (Healthcare Safety Investigation Branch, 2020, 2023).

Meeting people’s needs

2.1.17 Each investigation found further factors that contributed to patient misidentification. A potential theme was noted around the design of software and processes that did not account for the diversity of patient populations. Examples included limited consideration of the needs of patients who were unable to self-identify because of memory, reasoning or communication difficulties (Healthcare Safety Investigation Branch, 2022) and with respect to naming and date-of-birth conventions among specific populations.

‘… [The] first names and surnames of patients in South Asian communities could be used interchangeably. In relation to Patient 1, three names were recorded on the NHS Spine, while the Granddaughter gave the Patient’s first two names to the call assessor.’ Healthcare Safety Investigation Branch, 2021b

2.2 Ongoing misidentifications

2.2.1 Several investigations involved patients who went on to receive care under the wrong identifiers. Processes to verify a patient’s identity – for example, at handovers of care, referrals, or when undertaking tests or initiating treatment – did not detect the initial misidentification. At each of these points of care there was an associated local policy that required the patient’s identity to be verified. In practice, however, there was limited formal ongoing verification once the patient’s initial identification had been made.

2.2.2 In some cases, verifications did not occur because staff believed that other colleagues had already identified the patient (Healthcare Safety Investigation Branch, 2020, 2023). Other factors that contributed to ongoing misidentification were the same as for the initial misidentification.

2.2.3 Misidentifications were ultimately recognised by the patients themselves or their families (Healthcare Safety Investigation Branch, 2021a, 2021b), and in two investigations by hospital laboratories when samples were received for blood transfusion requests (Healthcare Safety Investigation Branch, 2019, 2022). The laboratory recognition of the misidentifications demonstrates the scrutiny in those processes.

2.2.4 The investigations in which patients or family members identified misidentifications highlights the role a person plays in their own safety. However, a person may not always be able to recognise that they have been misidentified and, where an issue was raised, it was not always acted on by staff (Healthcare Safety Investigation Branch, 2021b).

‘The Granddaughter noticed that the Patient’s demographic details, which had been printed in the [emergency department], had the wrong address and GP practice ... The nurse crossed out the incorrect address and GP practice and wrote the correct details. It was documented … that they had been “changed on the front sheet for the ward clerk to change [on the IT system] in the day”. This did not occur.’ Healthcare Safety Investigation Branch, 2021b

2.3 Use of the NHS number

2.3.1 Multiple investigations noted no or limited use of the NHS number (see section 1.1.4) in clinical practice to support patient identification (Healthcare Safety Investigation Branch, 2021a, 2021b, 2022, 2023). Examples of instances when the NHS number was not asked for included identification at the bedside, in outpatient clinics, and when first attending or admitting emergency patients.

‘Staff told the investigation that the NHS number was not commonly used at the bedside.’ Healthcare Safety Investigation Branch, 2023

2.3.2 The investigations explored factors that contributed to underuse of the NHS number. Factors noted included: limited or no direction in local policies for when staff should use NHS numbers; a normalised reliance on names for identification to speed up processes; wanting to avoid asking patients for their NHS number; and software systems that did not prompt or force the use of the NHS number.

2.3.3 There was also evidence that where the NHS number was used, staff relied on part of the number rather than matching the entire 10-digit number to patient records.

‘Typically, [staff] adopted a shortcut in using the last four digits of the NHS number to complete the matching task.’ Healthcare Safety Investigation Branch, 2021a

2.4 Controls to prevent patient misidentification

2.4.1 Each investigation considered the controls in place to prevent patient misidentification. Controls protect against threats/hazards (Chartered Institute of Ergonomics and Human Factors, 2016).

2.4.2 The investigations found that person (encouragement of individuals to act in a particular way), administrative (safety policies and procedures dictating how staff should undertake processes) and potentially engineered (designed to reduce the chance of an incorrect identifier being selected for a patient) controls were in place. The aim of the controls was to minimise the risk of patient misidentification (figure 2 (a)) and to capture misidentifications during subsequent verifications (figure 2 (b)). These controls were not always effective because additional factors (termed ‘degradation factors’) (see table 2) could undermine their reliability.

Figure 2 The threats and controls (grey boxes) found in HSIB investigations to (a) minimise the risk of patient misidentification and (b) minimise subsequent harm following patient misidentification

(a)

Image of figure 2 (a) showing the threats to patient misidentification and the possible controls to minimise the risk.

(b)

Image of figure 2 (b) showing the potential harm from patient misidentification and possible ways to minimise that harm.

Table 2 Summary of the degradation factors of the controls in figures 2 (a) and (b), as identified by HSIB investigations

Control Degradation factors Degradation factors Degradation factors Degradation factors
Engineered Software and/or safety-critical functionality not available in all settings Software/ technology accessibility and usability prevents use of relevant functionality Software/ technology availability limited by hardware and infrastructure Environment/ workspace not designed for the task or needs of staff
Administrative Policy describes work as imagined and does not account for work as done, leading to variation Policy is not informed by national standards, leading to variations in local application Staff influenced by the need for efficiency, distractions and interruptions Staff not told what they should be doing, or are unable to action a policy
Person Patient may be anxious or distracted Family or carers may not be present to support identification Staff may not use the patient or family to support identification

2.4.3 Several of the administrative controls were work practices that directed staff to undertake tasks through policies, procedures and checklists, while person-orientated controls relied on people doing something that they were not necessarily guided to do. Person and administrative controls were not always found to be successful.

“… amazing how many people … you can call a person by name and not the right person stands up.” Healthcare Safety Investigation Branch, 2021a

2.4.4 Some of the controls were potentially engineered, such as through alerts in software. Engineered controls should be more effective than administrative controls as they place less reliance on people (National Institute for Occupational Safety and Health, 2023). However, because engineered controls commonly involve prompts to staff, they could be considered administrative controls built into the software.

2.4.5 Figure 2 (a) highlights that the main control to prevent patient misidentification is the NHS number. The NHS number is included in several administrative and engineered controls but, as described in section 2.3, is not consistently used in clinical practice and therefore cannot be considered a strong control.

2.5 Summary

2.5.1 HSIB investigations identified a complicated array of interacting factors in different healthcare systems that contribute to misidentifying patients. Despite national direction to use the NHS number as the unique patient identifier, this does not always happen. Current controls to prevent misidentification rely on the people involved, including the patients themselves. These controls cannot be consistently depended upon to prevent patient misidentification or to identify where a misidentification has occurred.

3. HSIB’s previous safety recommendations and the published research literature

This section describes the findings of HSSIB’s review of:

  • HSIB’s safety recommendations and safety observations (together termed ‘safety interventions’) from investigations, and their role in managing the risk of patient misidentification
  • international literature around reducing the risk of patient misidentification.

3.1 Review of HSIB’s safety interventions

3.1.1 Relevant HSIB safety interventions from previous investigations were considered in relation to how they aimed to manage the risk of patient misidentification. Safety interventions were categorised using the framework in figure 3.

Figure 3 Categorisation of HSIB safety interventions for reducing the risk of patient misidentification

Image of figure 3 showing the categorisation of HSIB safety interventions for reducing the risk of patient misidentification.

3.1.2 Safety interventions aimed at reducing the risk of patient misidentification are categorised in appendix 6.4. None of the safety interventions were aimed at changing staff behaviour or eliminating the need to identify patients. Rather, they had the following aims:

  • Substitute the risk – replacing the information currently used for patient identification with more reliable information, and improving the use of systems that might more accurately facilitate the identification process (such as summary care records).
  • Engineer the risk – increasing the reliability and design of patient identification processes to help ensure the correct identifiers are attributed to a patient.
  • Administrative and additional interventions – assessing the effectiveness of existing processes to assure their safety and identifying further opportunities for improvement. Additional interventions included introducing identification procedures in settings where they did not previously exist, and training staff where knowledge was limited.

3.1.3 In general, safety interventions recommended developing systems and processes to support positive patient identification. None of the interventions is likely to be successful on its own, highlighting the need for multiple interventions at different levels. While engineering the risk may be most effective, training and procedures are also required.

Barriers to effective risk mitigation

3.1.4 Safety interventions are being implemented through national and local actions. Effectively implementing these safety interventions is expected to reduce the risk of patient misidentification but will not be able to eliminate the risk. The findings from HSSIB’s secondary analysis of the investigations (see section 2.1) highlight several potential barriers to effectively implementing the safety interventions (see table 2). These barriers relate to digital infrastructure, policy design and working conditions.

3.1.5 Digital infrastructure will be an important factor in the future development and implementation of more effective safety interventions to manage the risk of patient misidentification. To minimise the burden on staff when identifying patients, software needs to have the functionality to support identification, and hardware needs to be available. The lack of interoperability between different digital systems is also a known issue that affects the consistency and accuracy of patient information (Healthcare Safety Investigation Branch, 2023). There is a further risk and burden on staff when the information in systems cannot be trusted to be reliable.

3.1.6 A small number of the HSIB’s safety interventions focussed on introducing, clarifying and amending local procedures and policies for patient identification. While such procedures and policies have a limited ability to prevent incidents, they are important as part of a series of controls. Policies and procedures need to be well designed, unambiguous and accessible, and staff need to be aware of them. This is not always the case, as seen in several investigations (for example, Healthcare Safety Investigation Branch, 2021c).

3.1.7 HSIB investigations also highlighted that procedures are not always based on research evidence. An investigation into wrong site surgery found that there had been little research on patient identification processes in outpatient settings (Healthcare Safety Investigation Branch, 2021a). There is currently limited understanding of the most reliable ways of undertaking patient identification in different healthcare settings, and between staff and patients with varying needs.

3.1.8 Safety interventions that looked to engineer the risk of misidentification aimed to improve the reliability of identification processes. However, reliability requires other context-related factors to have been identified and optimised. Investigations identified several situations that undermine reliability, including limited staff induction and training (Healthcare Safety Investigation Branch, 2021b, 2022), redeploying staff to unfamiliar areas (Healthcare Safety Investigation Branch, 2023), and workspace designs that make it difficult to perform work as expected (for example, Healthcare Safety Investigation Branch, 2019).

3.2 Review of the literature

3.2.1 The aim of reviewing the literature was to identify new and developing opportunities to reduce the risk of patient misidentification. Searches identified 12 review articles (cited in appendix 6.5), published between 2009 and 2022, that were considered in this national learning report. The articles included systematic reviews such as from De Rezende et al (2021).

3.2.2 In summary, the literature review found the following:

  • Correctly confirming a patient’s identity depends on the accuracy, availability and usability of identifying information.
  • Identifying information may be in physical and/or electronic formats. Physical formats include identity wristbands and laboratory sample labels. Electronic formats include the electronic patient record.
  • Many healthcare settings rely on patients identifying themselves through a verbal communication process, such as in figure 1.
  • The reliability of different patient identification procedures has not been widely studied.
  • There is evidence that new technologies and ways of working can have a significant positive impact on patient identification.

Role of technology in identification

3.2.3 There is much focus in the literature on technology and its role in supporting patient identification. The term ‘technology’ encompasses the physical design of patient identifiers, the functionality and usability of electronic patient identifiers, the use of devices to support patient identification, and implementing information standards.

3.2.4 The use of technology designed to help staff identify patients has shown significant reductions in misidentification incidents in research. As per De Rezende et al’s (2021) systematic review, examples of technology include functionality of test ordering systems, patient photographs in electronic records, and barcode patient identification. However, the systematic review also described the quality of evidence to be ‘very low’ due to limitations in study designs.

3.2.5 Not all the technologies that have been studied have been able to demonstrate sustainable changes to the practice of patient identification, and some have led to the loss of earlier improvements in safety. Staff adaptations (where staff bypass a problem or limitation found in the technology) continue to pose problems for implementing and sustaining the use of many technologies, including barcode/QR code systems. Those adaptations are required because the design of the technology has not considered the system within which it is to be implemented. Adaptations were found in the research literature in system-level patient matching, order entry and charting, medication management, point-of-care testing, radiology and laboratory medicine, including transfusion and pathology (see appendix 6.5).

3.2.6 The need for staff adaptations suggests that technology has been introduced without recognising what staff need to do their jobs effectively. This highlights how technology alone cannot remove the risk of patient misidentification. Work systems – involving people, technology and tools – need to be designed to support improvements in the reliability of identification processes.

3.3 Summary

3.3.1 This review of HSIB’s safety recommendations and safety observations using an aggregated approach suggests that it is not yet possible to eliminate the risk of patient misidentification. Rather, a series of safety interventions are needed to attempt to control the risk. For those interventions to succeed, the workplaces within which they are implemented need to be fully understood and optimised to support effective implementation.

3.3.2 The research literature describes opportunities for the increased use of technology to support patient identification. Workplaces need to be designed to support the use of technology, but it must be recognised that technology alone is unlikely to be solve the problem of patient misidentification.

4. Reducing the risk of patient misidentification

This section draws together the findings of this national learning report (NLR) by first summarising what has been found about the risk of patient misidentification, and then considering how the risk can be further mitigated.

This NLR has found that the risk of patient misidentification is present, persistent and complex. Current controls are unable to prevent all misidentifications, but there are opportunities to better support staff in identifying patients by improving their working conditions, particularly in situations and settings where there is a higher risk of misidentification.

4.1 The risk of patient misidentification

4.1.1 The process of patient identification is complex and safety-critical. It requires staff to adapt to varying and often changing circumstances, and there is potential for significant harm if a patient is misidentified. Multiple interacting factors influence the performance of staff (see section 2.1), and it is therefore unlikely that each patient identification and verification will be accurate.

4.1.2 However, the risk of misidentification is likely under-recognised and potentially unknown (see section 1.2), and this restricts the resources allocated by local and national bodies to further mitigate the risk. This is demonstrated by a response from NHS England and NHS Improvement to a safety recommendation made in one HSIB investigation, which said: ‘Our assessment is that this work would require determination of the true scale and impact of the risks identified … At this time, there is insufficient evidence that the scale of this risk would justify such a reallocation of the available resources’ (Healthcare Safety Investigation Branch, 2021a).

4.1.3 The finding of the current NLR, which has drawn together learning from several HSIB investigations, is that the risk of patient misidentification is currently not controlled. Controls depend on healthcare staff following policies and using a patient’s NHS number (see section 4.1.5), but it is not known what a ‘good’ check of a patient’s identity looks like. Staff are responsible for correctly identifying patients and are held accountable when misidentifications occur. While staff are supported by some safeguards, such as barcode technology, they are not reliably present, used or effective in practice.

4.1.4 In the future, organisations may seek to automate patient identification and remove the need for staff to undertake the process. In the meantime, there should be continued efforts to understand and reduce the risk of misidentification. During the development of this NLR, it became apparent that allocating already limited safety resources to the challenge of patient misidentification would mean removing resources from elsewhere, and this would have to be justified. As such, further research is needed to understand the risks of patient misidentification and where efforts to mitigate that risk can be best aimed for maximal impact. The degradation factors identified in table 2 may help inform this research.

HSSIB makes the following safety recommendation

Safety recommendation R/2024/017:

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.

HSSIB makes the following safety observation

Safety observation O/2024/013:

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.

Supporting use of the NHS number

4.1.5 HSSIB recognises that the above safety recommendation and any resulting improvement programmes will take time to impact on patient safety. In the meantime, the main control for reducing the risk of patient misidentification is the NHS number.

4.1.6 Through this review of HSIB investigations and the research literature, and discussions with national bodies, several factors meaning that the NHS number is not consistently used as the unique patient identifier were identified (see box 2). While using the NHS number alone will not prevent all patient misidentifications, its use as a consistent and unique number is an important part of reducing misidentifications.

Box 2 Why is the NHS number not consistently used? Summary of findings

  • The number itself:

- Concerns from the public around the privacy of the NHS number.

- Staff may not trust that the NHS number is unique.

- The length of the number (10 digits) means it is not easily remembered.

- The number does not represent how people naturally communicate with each other, as opposed to name and date of birth that are used in everyday life.

  • Availability and understanding:

- Some people do not have NHS numbers (such as those crossing from Scotland for care in England and refugees).

- There is limited knowledge of the role and importance of the NHS number among both patients and staff.

- The NHS number is not consistently used across all of health and social care in paper and electronic systems.

  • Organisational factors:

- Hospital policies may ask staff to use a hospital number rather than the NHS number.

- Policies and procedures vary in their inclusion of the NHS number.

- Longstanding underuse of the NHS number has led to normalised use of the patient’s name and date of birth for identification.

  • Individual factors:

- Patients do not always know their NHS number.

- Staff may believe that the NHS number is not required or is only needed for appointments.

- Staff are reluctant to ask patients for their NHS number every time.

4.1.7 HSSIB has heard concerns among some staff that a person’s NHS number may not always be unique. Several hospital policies, reviewed by HSSIB, therefore ask staff to use local hospital numbers instead of the NHS number (Healthcare Safety Investigation Branch, 2023). In rare circumstances a person may have multiple NHS numbers (Primary Care Support England, n.d.) as a result of multiple registrations with the NHS. Multiple NHS numbers were seen in one of the HSIB investigations (Healthcare Safety Investigation Branch, 2022) and HSSIB has been told of babies with multiple numbers who have been born to mothers claiming asylum in England. It may also be possible for two patients to have the same NHS number, termed ‘confusions’ (Primary Care Support England, n.d.).

4.1.8 However, concerns around the uniqueness of the NHS number do not appear to be the most important factor in its underuse. Rather, HSIB investigations suggested that it is more common that local conditions do not support its use. Conditions include all elements of the work system (such as resourcing and infrastructure) and the design of policies, processes, environments and technologies. Unsupportive conditions lead to staff adapting their practices, which can increase the risk of misidentification.

4.1.9 The need to optimise the conditions within which staff work to support safer care was a regular finding of HSIB’s investigations. The beneficial role of specialists in human factors and ergonomics in helping to apply the principles of user-centred design to optimise working conditions has been observed by several investigations. Specialists in user-centred design can help to optimise work system elements such as environments and workspaces (for example, Healthcare Safety Investigation Branch, 2019), and work procedures (for example, Healthcare Safety Investigation Branch, 2021c).

HSSIB makes the following safety observations

Safety observation O/2024/014:

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.

Safety observation O/2024/015:

Healthcare organisations can improve patient safety by assessing and addressing their local barriers to using the NHS number for patient identification.

4.2 Other opportunities to reduce patient misidentification

4.2.1 This NLR has identified several high-risk settings/situations for patient misidentification, and potential opportunities to further mitigate the risk. The following sections explore these high-risk settings/situations and the role of technology in supporting patient identification.

High-risk settings and situations

4.2.2 The risk of patient misidentification is greater during certain activities. HSIB investigations found handovers and transfer of patient care to be high-risk activities, while the research literature describes patient transfers, emergency care, laboratory investigations, medication processes, invasive procedures and diagnostic imaging as high-risk activities (Abraham et al, 2021; Bolton-Maggs et al, 2015; Emergency Care Research Institute, 2016; Levin et al, 2012; Mannos, 2003; Suclupe et al, 2022; Tozbikian et al, 2017).

4.2.3 The process of handing over patient care between staff is frequent and safety-critical. In the investigation into access to critical patient information at the bedside, it was noted that information could be lost at handover and that there was significant variability in how handovers are undertaken, including in how patients are identified (Healthcare Safety Investigation Branch, 2023). The research literature also describes how hospital handovers are often not performed in line with the expectations of a policy (Suclupe et al, 2022). HSIB made a safety recommendation to the Royal College of Nursing to help create the conditions for more effective handovers (Healthcare Safety Investigation Branch, 2023).

4.2.4 HSIB investigations also found a risk of patient misidentification when patient care is transferred between community healthcare organisations, ambulance trusts and hospital trusts (Healthcare Safety Investigation Branch, 2021b, 2022). The investigations made safety observations around the benefits of reducing the variability in identification processes across regions. With the now statutory duties of integrated care boards, they have a role in supporting standardisation and assuring the safety of processes across their geographical footprints.

HSSIB suggests the following safety action for integrated care boards

Suggested safety action ICB/2024/004:

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.

4.2.5 In support of the above suggestion for integrated care boards, HSSIB met with the Care Quality Commission to explore its role in supporting safety in integrated care systems. The 'integration' theme of the Care Quality Commission’s ‘Assessment framework for integrated care systems’ addresses safe systems, pathways and transitions (Care Quality Commission, 2023). As such, the Care Quality Commission can support improvements in patient identification across systems through its assurance process

HSSIB makes the following safety recommendation

Safety recommendation R/2024/018:

HSSIB recommends that the Care Quality Commission develops its methodology for assessment of integrated care systems and organisations to include arrangements for the positive identification of patients at transfer between healthcare organisations. This is to reduce variability in processes and what information is used for identification.

Accounting for the diversity of the population

4.2.6 HSIB investigations suggested that some patient groups are at greater risk of being misidentified (see section 2.1.17). Examples include people who do not speak English; those who are unconscious or have cognitive impairment; those with communication difficulties; and patients with similar identifying information to another person. This diversity again highlights the need for processes to be designed in a user-centred manner, as per safety observation 2024/014 (see section 4.1.9).

4.2.7 Regarding cognitive impairment, investigations found an increased likelihood of misidentification where patients are unable to identify themselves or be part of the identification process (for example, Healthcare Safety Investigation Branch, 2022). Policies and procedures were found to focus on patients who could respond to questions about their identity, and to rely on families and carers to support the identification of patients who could not self-identify (Healthcare Safety Investigation Branch, 2022, 2023). This safety risk is likely to be widespread and will increase as the population ages and people live longer. A study published in 2017 found that 31% of hospitalised patients aged 75 years or older had dementia or another form of cognitive impairment (Fogg et al, 2017).

4.2.8 HSIB’s first local integrated investigation found that the limited ability of NHS systems and processes to recognise the naming and date-of-birth conventions of some communities contributed to patient misidentification (Healthcare Safety Investigation Branch, 2021b). This finding highlights a under-recognised risk that NHS systems and processes are not designed with local population needs in mind. England is a culturally diverse country (Office for National Statistics, 2022), and the risk of patient misidentification will be further increased where people do not speak English as a first language.

4.2.9 There is a need to ensure systems and processes do not disadvantage people with particular characteristics. The above findings suggest that people may be disadvantaged because of their disability, illness or cultural background, and so due regard needs to be given to meeting the needs of different patient groups. This includes ensuring local populations are understood and represented in system designs.

HSSIB makes the following safety observation

Safety observation O/2024/016:

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.

The role of technology in patient identification

4.2.10 The delivery of patient care is becoming increasingly reliant on and augmented by technology and software. Examples include the electronic patient record (EPR), electronic prescribing and administration systems, and electronic systems for presenting observations and test results. There are also increasing examples of barcode and QR code scanning technologies being used to support the matching of patients to equipment or records; the DCB1077 standard defines how to encode ‘NHS approved patient identifiers’ into barcodes (NHS Digital, 2020). However, it was found that implementing technological solutions for patient identification is limited by the technology available and its local implementation.

Available technology

4.2.11 HSIB previously made safety recommendations in support of improving the accessibility of critical patient information in EPR systems (Healthcare Safety Investigation Branch, 2023). This NLR reiterates the importance of those safety recommendations to ensure staff can access clear information about a patient’s identity, and of configuring local systems in a way that supports access to information.

4.2.12 HSSIB’s review of the research literature found reports of various forms of technology used to support the identification and verification of patients (see section 3.2). At present, technology has the potential to mitigate the risk of patient misidentification, but it is not clear which technology is most effective at controlling the risk in different settings.

4.2.13 HSSIB approached NHS England to explore national programmes for evaluating and integrating technology to support patient identification. HSSIB was told about the Scan4Safety programme and its potential to track products and people through the supply chain and across hospitals (Department of Health and Social Care, 2021). Scan4Safety uses GS1 standards (a global set of data to allow unique coding of equipment and people), and codes for patients can be incorporated into identity wristbands. HSSIB was told by the programme team that Scan4Safety has further potential to supporting patient identification (GS1 UK, n.d., NHS Digital, 2020).

HSSIB makes the following safety recommendation

Safety recommendation R/2024/019:

HSSIB recommends that NHS England reviews and identifies system-wide requirements for scanning in positive patient identification. This is to support local organisations to use scanning technology to reduce misidentification incidents.

Local implementation of technology

4.2.14 HSSIB engaged with a ‘digitally mature’ hospital that is implementing a code scanning system. The hospital described how scanning a code on a patient’s identity wristband (attached to each patient on admission) using a handheld device opens up the patient’s EPR. This provides access to EPR at the bedside and removes the need for staff to manually select the patient’s record, thus minimising the risk of mis-selection. Staff are still required to identify the patient to check they have the correct wristband.

4.2.15 The hospital team described factors that led to staff adapting the way they used the scanning system. The factors were similar to those found by HSSIB’s other investigations, such as limited availability of the handheld devices. Other issues noted included that the devices did not have a torch, so could not scan at night (without turning a ward light on). The research literature highlights the potential risks of adaptations to barcode systems (for example, Koppel et al, 2008).

4.2.16 The issue of adaptations highlights the need for healthcare organisations and technology manufacturers to understand the needs of the user and the reality of work as done. Local configuring of technology by digital teams has been previously found to sometimes introduce risks where staff needs have not been fully considered (for example, Healthcare Safety Investigation Branch, 2021d). Clinical risk management standards are available to support clinical safety when manufacturing, deploying and using health IT systems (NHS Digital, 2018a, 2018b); they are mandatory under the Health and Social Care Act 2012. In particular, standard DCB0160 requires organisations to establish a framework within which the clinical risks associated with deploying and implementing a new or modified health IT system are managed (NHS Digital, 2018b); this includes that any release is backed by a safety case (that is, documentation of the risks and how they have been mitigated).

HSSIB makes the following safety observation

Safety observation O/2024/017:

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).

4.3 Rectifying misidentifications

4.3.1 This NLR predominantly focusses on preventing patient misidentification. However, as it is not currently possible to fully eliminate the risk, misidentifications will continue to occur. This means that processes are required to address misidentifications after they have been detected, and to ensure that a patient’s records are reviewed and made accurate.

4.3.2 HSIB investigations found challenges when attempting to rectify misidentifications (Healthcare Safety Investigation Branch, 2020, 2021b, 2022). Particular problems are encountered where patients have been cared for across multiple organisations, care pathways and episodes of care, and where hybrid (electronic and paper) systems are used to manage patient care.

4.3.3 The patient narrative in section 2 highlights the challenge of rectifying misidentifications and the lost opportunities to learn from misidentifications. HSSIB was told by the organisations involved that it can be difficult to identify inaccuracies when patients have similar names, ages and medical conditions. The functionality of digital systems and lack of interoperability between systems means that information may become stored in different places, rather than in a central location. This can create a continuing safety risk if incorrect information is not identified or addressed, and further highlights the need for interoperable digital systems.

HSSIB suggests the following safety action for integrated care boards

Suggested safety action ICB/2024/005:

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.

4.4 Assuring the safety of the patient identification processes

4.4.1 Positive patient identification is a fundamental healthcare process. However, it is unreliable, and the risk of misidentification has been recognised for many years. Despite this, it is hard to understand the risk (see section 1.2.6) and national resources are being prioritised to manage incidents which are perceived to represent the greatest harm (see section 4.1.1).

4.4.2 The need to see evidence of harm before a safety risk is addressed suggests a reactive approach to safety management. The reactive approach, which seeks to build a case for safety improvements based on quantifying harm, contrasts with modern views of safety and its improvement.

Proactive approach to safety management

4.4.3 Patient misidentification has been described as a ‘wicked problem’ (Ferguson et al, 2019), and the concept of a wicked problem is defined in the research literature (Lönngren and van Poeck, 2021). Patient misidentification is a wicked problem because it is not fully understood, the various factors that contribute to it are complex, there are many people involved in its occurrence and attempting to prevent it, solutions have potential ramifications for the wider healthcare system, and proposed solutions to date have been ineffective.

4.4.4 To address wicked problems, it may be necessary to think differently about how a safety risk is understood and mitigated. This may include moving away from reacting to incidents to proactively looking to understand systems and assure the safety of processes. HSSIB previously discussed the potential role of proactive approaches to safety in healthcare through a safety management system (Health Services Safety Investigations Body, 2023). A safety management system offers an organised and proactive way of understanding the risk of misidentification. It would focus on improving systems for patient identification, and then proving that those systems can consistently assure the correct patient is identified.

HSSIB makes the following safety observation

Safety observation O/2024/018:

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.

Addressing the risk further

4.4.5 Because current controls to prevent patient misidentification have limited effectiveness, misidentifications will continue to occur. The risk of patient misidentification, while not fully understood, will be mitigated to a certain level by the current controls. The level of mitigation will depend upon the situation and setting within which patient identification is being undertaken.

4.4.6 Non-healthcare industries talk about controlling risks to be ‘as low as reasonably practicable.’ The concept of ‘reasonably practicable’ involves ‘weighing a risk against the trouble, time and money needed to control it’ (Health and Safety Executive, n.d.). This concept is not well recognised in healthcare. It is also contentious, because it acknowledges that there will be a point where it is not practicable to attempt to mitigate a risk further and at which it is accepted that some incidents will still occur.

4.4.7 At present, it remains possible to further reduce the risk of patient misidentification, such as through the safety interventions suggested by HSIB (see section 3.1) and by monitoring research publications in this area (see section 3.2). However, national bodies are currently unable to allocate further resources to addressing the risk (see section 4.1). It is therefore unknown whether it is practicable to further address the risk of patient misidentification. When a better understanding has been gained of the risk (as per safety recommendation R/2024/017) and the resources available to address it have been considered, practicability may need to be considered nationally.

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Lippi, G., Mattiuzzi, C., et al. (2017) Managing the patient identification crisis in healthcare and laboratory medicine. Clinical Biochemistry, 50(10–11), pp. 562–567. doi: 10.1016/j.clinbiochem.2017.02.004

Lönngren, J. and van Poeck, K. (2021) Wicked problems: a mapping review of the literature. International Journal of Sustainable Development & World Ecology, 28(6), pp. 481–502. doi: 10.1080/13504509.2020.1859415

Mannos, D. (2003) NCPS patient misidentification study: a summary of root cause analyses. Topics in Patient Safety, June–July 2003. Available at https://www.patientsafety.va.gov/docs/TIPS/TIPS_Jul03.pdf (Accessed 22 December 2022).

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National Patient Safety Agency (2004) Right patient – right care: framework for action. Available at http://brenmoor.com/wp-content/uploads/2015/08/right-patient-right-care.pdf (Accessed 25 March 2022).

National Patient Safety Agency (2005) Safer practice notice: wristbands for hospital inpatients improves safety. Available at https://webarchive.nationalarchives.gov.uk/ukgwa/20171030131037/http:/www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59799%26p=4 (Accessed 25 March 2022).

National Patient Safety Agency (2007) Safer practice notice: standardising wristbands improves patient safety. Available at https://webarchive.nationalarchives.gov.uk/ukgwa/20171030131015/http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59824%26p=3 (Accessed 25 March 2022).

National Patient Safety Agency (2009) Safer practice notice: risk to patient safety of not using the NHS number as the national identifier for all patients. Available at https://webarchive.nationalarchives.gov.uk/ukgwa/20171030130740/http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=61913&p=2 (Accessed 25 March 2022).

NHS (2019) What is an NHS number? Available at https://www.nhs.uk/using-the-nhs/about-the-nhs/what-is-an-nhs-number/ (Accessed 13 December 2022).

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NHS Digital (2020) DCB1077: AIDC for patient identification. Available at https://digital.nhs.uk/data-and-information/information-standards/information-standards-and-data-collections-including-extractions/publications-and-notifications/standards-and-collections/dcb1077-aidc-for-patient-identification (Accessed 30 March 2023).

NHS Improvement (2018a) Safer temporary identification criteria for unknown or unidentified patients. Available at https://www.england.nhs.uk/wp-content/uploads/2019/12/Patient_Safety_Alert_-_unknown_or_unidentified_patients_FINAL.pdf (Accessed 4 July 2023).

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Phillips SC, Saysana M, Worley S, Hain PD. (2012) Reduction in pediatric identification band errors: A quality collaborative. Pediatrics, 129(6), e1587-93

Phipps, E., Turkel, M., et al. (2012) He thought the “lady in the door” was the “lady in the window”: a qualitative study of patient identification practices. Joint Commission Journal on Quality and Patient Safety, 38(3), pp. 127–134. doi: 10.1016/s1553-7250(12)38017-3

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Sevdalis, N., Norris, B., et al. (2009) Closing the safety loop: evaluation of the National Patient Safety Agency’s guidance regarding wristband identification of hospital inpatients. Journal of Evaluation in Clinical Practice, 15(2), pp. 311–315. doi: 10.1111/j.1365-2753.2008.01004.x

Serious Hazards of Transfusion (2021) Annual SHOT report. Available at https://www.shotuk.org/wp-content/uploads/myimages/SHOT-REPORT-2021-FINAL-bookmarked-V3-November.pdf (Accessed 22 December 2022).

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Suclupe, S., Kitchin, J., et al. (2022) Evaluating patient identification practices during intrahospital transfers: a human factors approach. Journal of Patient Safety, 19(2), pp. 117–127. doi: 10.1097/PTS.0000000000001074

Tozbikian, G., Gemignani, M.L., et al. (2017) Specimen identification errors in breast biopsies: age matters. Report of two near-miss events and review of the literature. The Breast Journal, 23(5), pp. 583–588. doi: 10.1111/tbj.12797

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Walley, S.C., Berger, S., et al. (2013) Decreasing patient identification band errors by standardizing processes. Hospital Pediatrics, 3(2), pp. 108–117. doi: 10.1542/hpeds.2012-0075

Waruhari, P., Babic, A. et al. (2017) A review of current patient matching techniques. Studies in Health Technology and Informatics, 238, pp. 205–208.

6. Appendices

6.1 Approach to this national learning report

Decision to launch this report

Outcome impact – what is the impact of the safety issue on people and services across the healthcare system?

HSIB investigations demonstrated the physical and psychological harm that can result from patient misidentification. Examples included a patient who received an invasive procedure not meant for them; a patient who bled after receiving anticoagulation medication not meant for them; and a patient who did not undergo a resuscitation attempt because it was thought he was a different patient.

Systemic risk – how widespread and how common a safety issue is this across the healthcare system?

HSIB investigated patient misidentification in secondary care (outpatients, medical wards, operating theatres and emergency departments), the ambulance service and care homes. Intelligence from HSIB referrals and national incident databases shows that misidentifications continue to occur across healthcare. The continuing occurrence of misidentification incidents across all areas of healthcare, despite national efforts to improve safety, suggests a common and ongoing risk.

Learning potential – what is the potential for an HSSIB investigation to lead to improvements to patient safety across the healthcare system?

Efforts to address patient misidentification have not always been successful. Internationally, patient misidentification is a persistent problem. This national learning report has the potential to influence safety improvements through safety recommendations informed by HSSIB’s human factors based, system-focussed approach and a review of the research literature.

Objectives of this report

The objectives of this national learning report were to:

  • describe previous relevant HSIB investigations
  • combine the findings from HSIB investigations to summarise the factors that have contributed to patient misidentifications
  • review HSIB safety recommendations and safety observations to explore their role in reducing the risk of patient misidentification
  • conduct a review of the international research literature to identify additional opportunities to reduce patient misidentification
  • synthesise and summarise the findings, and develop safety recommendations and safety observations to aid in further reducing the risk of patient misidentification.

Evidence sources

This report reviewed previous HSIB investigations that, fully or in part, considered events where a patient was misidentified. Summaries of those investigations are provided in appendix 6.2 and the individual reports are available via the HSSIB website.

Further evidence included additional referrals to HSIB that involved patient misidentifications, the Strategic Executive Information System (StEIS), national patient safety policy and safer practice alerts, and the international research literature.

Secondary analysis

Secondary analysis refers to analysing evidence that has been collected by someone else. In this report, the evidence included previous HSIB investigations. Investigation reports were analysed using qualitative analysis software (NVivo 12; QSR International, n.d.) to identify themes in the factors that contribute to patient misidentification. Analysis followed a recognised methodology (Braun and Clarke, 2006) using HSSIB’s framework, which is based around the Systems Engineering Initiative for Patient Safety (Carayon et al, 2006, 2014, 2020). Theming was undertaken by one national investigator and one intelligence analyst, both with experience in qualitative research.

The analysis also considered the availability of controls (Chartered Institute for Ergonomics and Human Factors, 2016) and their effectiveness in preventing patient misidentification or identifying where a patient misidentification has occurred. Findings are summarised in section 2.

Analysing HSIB’s contribution to risk management

Safety recommendations and safety observations (termed together as ‘safety interventions’) made in the HSIB investigations were reviewed. These safety interventions represent HSIB’s contribution to managing and reducing the risk of patient misidentification.

The analysis involved describing how the interventions aimed to manage the risk of patient misidentification. To do this, HSSIB adapted the hierarchy of controls (The National Institute for Occupational Safety and Health, 2023) to use as a framework (see figure 3). HSSIB acknowledges that the hierarchy does not originate in healthcare and is therefore of limited applicability. However, it was used to help categorise and exemplify the levels of the system at which the interventions are aimed. Findings are summarised in section 3.

Review of the literature

A search of the literature was undertaken using the Scopus and PubMed databases. Relevant articles, published between 2009 and to 2022, were identified using keyword and subject heading searches. The following were searched for: wrong-patient incidents (including medication incidents), positive patient identification processes and technologies, and misidentification associated with healthcare processes.

Searches identified 12 review articles (cited in appendix 6.5). Findings are summarised in section 3.

Developing safety recommendations

The findings of the above analyses were combined to draw conclusions about: 1) why patient misidentifications continue to occur, and 2) potential opportunities to further reduce the risk of misidentification. The findings were shared with NHS England and the Care Quality Commission in support of developing safety recommendations and safety observations.

6.2 Summary of HSIB investigations that considered identification of patients

Local integrated investigation pilot 1: incorrect patient identification (Healthcare Safety Investigation Branch, 2021b)

Setting Summary Outcome Safety interventions
Ambulance
Emergency department
Hospital wards
Patient 1 was taken to hospital by ambulance. The emergency operations centre used the wrong NHS number for patient 1. They used the NHS number of patient 2, who had the same date of birth as patient 1 and a similar name.

Part of HSIB’s local investigation pilot, with no national investigation.
Potential for the patient to receive the wrong care. HSIB recommends that:
… the Ambulance Trust develops and implements a standardised approach to patient identification in the emergency operations centre.
… the Acute Trust develops and implements a standardised approach to patient identification in the emergency department.
… the Acute Trust explores the barriers to checking three identifiers when confirming a patient’s identification for their wristband, and takes appropriate action.
… the Acute Trust work with the Ambulance Trust to develop and implement a standardised approach to verifying and confirming a patient’s identification during the handover process.

It may be beneficial if:
… the Ambulance Trust develops mechanisms to capture the NHS number at the point of initial contact.
… further national work is undertaken on the use of the NHS number as a unique identifier, specifically in identifying patients.
… the Acute Trust considers the interoperability of its IT systems (that is, the ability of different IT systems to communicate and share information) as part of its digital strategy and in future procurement.
… the Ambulance Trust adjusts its call audit tool to assess whether patient identification is correctly confirmed.

Local integrated investigation pilot 2: incorrect patient details on handover (Healthcare Safety Investigation Branch, 2022)

Setting Summary Outcome Safety interventions
Nursing home
Ambulance
Emergency department
Hospital wards
Operating theatre
The patient had dementia and was taken by ambulance to hospital after a fall in her nursing home. The emergency department was unable to find the patient’s details on its digital system and so a new patient record was created with the incorrect details.

Part of HSIB’s local investigation pilot, with no national investigation.
Potential for the patient to receive the wrong care. HSIB recommends that:
… the nursing home implements a mechanism to use care records with the lowest risk of having incorrect personal identification data during interactions with the wider healthcare system.
… the Ambulance Trust carries out additional personal identification data verification when a successful Patient Demographic Service search via NHS Spine has not been achieved.
… the Acute Trust, in collaboration with the Ambulance Trust, develops and implements a formal emergency department booking-in policy.
… the Acute Trust carries out additional personal identification data verification when an NHS number is not available.
… the Acute Trust tests its positive patient identification procedure for patients with dementia in order to identify risks and support the development of effective mitigating controls.

It may be beneficial if:
… the Acute Trust reviews the infrastructure and layout of the emergency department majors area in order to support the flow co-ordinator to reliably carry out their full responsibilities.
… the Acute Trust considers the results of current research to understand whether a way of visually identifying patients with dementia would be appropriate to help positive patient identification.

Wrong site surgery – wrong patient: invasive procedures in outpatient settings (Healthcare Safety Investigation Branch, 2021a)

Setting Summary Outcome Safety interventions
Outpatient department Patient A visited an outpatient department for a fertility treatment appointment. Patient B attended at a similar time for a colposcopy appointment. A nurse called out patient B’s first name and surname. She then called patient B’s first name. Patient A’s surname was similar to patient B’s first name and, as no other person had responded, patient A believed the nurse must be calling for her. Patient received a procedure not meant for them. HSIB recommends that:
… NHS England and NHS Improvement leads a review of risks relating to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise. This should assess the feasibility to enhance or implement layers of systemic controls to manage these risks. It should also consider existing challenges relating to the usability and practice of including the NHS unique identifier in patient identification processes, and consider technological solutions to support its use.

It would be beneficial if:
… it was easier for trusts to find clear national guidance on what a good patient identification check looks like to assist the quality and consistency of trust guidance.
… there was national guidance on the principles for good design of tools to support the critical task of patient identification.
… the risks associated with patient identification in an outpatient department are considered within staff education and in the procurement and implementation of technical systems.

Wrong patient details on blood sample (Healthcare Safety Investigation Branch, 2019)

Setting Summary Outcome Safety interventions
Maternity unit A midwife collected two blood samples: a sample from patient A and a sample from patient B. When laboratory staff received the samples, they noted that both sets of blood samples had been labelled with patient A’s details, but one set had been sent with patient B’s blood test request form. Potential for the patient to receive the wrong blood in case of transfusion. HSIB recommends that:
… NHSX should take steps to ensure the adoption and ongoing use of electronic systems for identification, blood sample collection and labelling.

The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital (Healthcare Safety Investigation Branch, 2020)

Setting Summary Outcome Safety interventions
Medical admission unit
Hospital wards
The patient was prescribed warfarin, and a warfarin medication chart was present in his records. The prescription appeared to have resulted from one of the patient’s identification stickers being mistakenly attached to another patient’s warfarin chart. Patient received a medication not meant for him and came to harm. None applicable.

Access to critical patient information at the bedside (Healthcare Safety Investigation Branch, 2023)

Setting Summary Outcome Safety interventions
Hospital ward A patient was found unresponsive in bed on a hospital ward. The team confirmed the patient’s identity and noted that a decision had been made that he was not recommended to receive cardiopulmonary resuscitation (CPR) if his heart stopped. CPR was not started. Ten minutes later, a nurse recognised that the patient had been misidentified as the patient in the next bed. The patient was recommended to receive CPR. Delay to emergency treatment of the patient. HSIB recommends that:
… the Office of the National Data Guardian supports local interpretation of the Caldicott Principles to give organisations and staff the confidence to display full patient names at the bedside to support correct patient identification for safer care.
… NHS England develops guidance to providers, via any digital maturity assessments that are developed, to help ensure critical patient information (such as patient identifiers and cardiopulmonary resuscitation status) is available to clinical staff when accessing electronic patient record systems.
… NHS England provides guidance to healthcare organisations to support local design and configuration of electronic patient records to enable end users to access critical patient information (such as patient identifiers and cardiopulmonary resuscitation status).
… NHS England, during review of relevant Health Building Notes and Technical Memoranda, includes, as a consideration, that bedside patient information should be consistently visible.
… 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.

It may be beneficial for:
… healthcare organisations to provide guidance to support decisions in clinical areas that balance confidentiality and the visibility of critical patient information for patient safety.
… healthcare organisations to assess their information technology infrastructure needs, such as equipment availability and network coverage, to enable staff to consistently access critical patient information.

6.3 Coding framework from the secondary analysis of HSIB investigations that considered misidentification of patients

Factors contributing to misidentification of patients

Theme Number of investigations identified
1 External 2
Lack of interorganisational communication of identification arrangements 1
National direction not followed locally 2
2 Organisational 5
Limited or no relevant training related to identification 3
Limited resources to support identification 2
Identification process not designed for safety 5
Risks around misidentification not recognised or mitigated 5
Thoroughness traded for efficiency with demand 4
3 Environment 6
Workspace design influencing patient identification 5
Workspace distractions 3
4 Technology 6
Design of blood sample bottles makes them difficult to write on 1
Digital functionality does not support safe identification practice 4
Influence of interoperability of multiple systems 2
Infrastructure and accessibility to digital systems 3
Mix of paper and digital systems 4
5 Staff and task 6
Assumptions, trust and limited questioning 5
Individual variation in task performance 4
Knowledge and skill 1
Shortcuts and workarounds when undertaking safety-critical tasks 4
6 Patient 4
Not accounting for diverse patient needs 2
Reliance on the patient to support identification 1
Similarity between patients 1

Factors contributing to verification processes not identifying an initial misidentification

Theme Number of investigations identified
1 External 1
Limited national guidance on best practice 1
Risk management and limited controls 1
2 Organisation 4
Limited or no relevant training related to identification 1
Identification process not designed for safety 4
Risks around misidentification not recognised or mitigated 1
Thoroughness traded for efficiency with demand 3
3 Environment 1
Workspace distractions 1
4 Technology 3
Digital functionality does not support safe identification practice 3
Influence of interoperability of multiple systems 1
Mix of paper and digital systems 1
5 Staff and task 4
Assumptions, trust and limited questioning 4
Individual variation in task performance 3
Shortcuts and workarounds when undertaking safety-critical tasks 2
6 Patient 2
Not accounting for diverse patient needs 2
Not accounting for similarities between patients 1

6.4 Categorisation of safety interventions versus the level of risk management

Risk management approach Safety intervention Safety
intervention
Eliminating the risk None
Substituting the risk HSIB recommends that… … the Nursing Home implements a mechanism to use care records with the lowest risk of having incorrect personal identification data during interactions with the wider healthcare system.
… the Ambulance Trust carries out additional personal identification data verification when a successful Patient Demographic Service search via NHS Spine has not been achieved.
… the Acute Trust carries out additional personal identification data verification when an NHS number is not available.
… NHSX should take steps to ensure the adoption and ongoing use of electronic systems for identification, blood sample collection and labelling.
… NHS England develops guidance to providers, via any digital maturity assessments that are developed, to help ensure critical patient information (such as patient identifiers and cardiopulmonary resuscitation status) is available to clinical staff when accessing electronic patient record systems.
… 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.
Substituting the risk It may be beneficial if (observation)… … further national work is undertaken on the use of the NHS number as a unique identifier, specifically in identifying patients.
… the Acute Trust considers the interoperability of its IT systems (that is, the ability of different IT systems to communicate and share information) as part of its digital strategy and in future procurement.
… the Acute Trust considers the results of current research to understand whether a way of visually identifying patients with dementia would be appropriate to help positive patient identification.
Engineering the risk HSIB recommends that… … the Ambulance Trust develops and implements a standardised approach to patient identification in the emergency operations centre.
… the Acute Trust develops and implements a standardised approach to patient identification in the emergency department.
… the Acute Trust work with the Ambulance Trust to develop and implement a standardised approach to verifying and confirming a patient’s identification during the handover process.
… NHS England and NHS Improvement leads a review of risks to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise. This should assess the feasibility to enhance or implement layers of systemic controls to manage these risks. It should also consider existing challenges relating to the usability and practice of including the NHS unique identifier in patient identification processes, and consider technological solutions to support its use.
… NHS England provides guidance to healthcare organisations to support local design and configuration of electronic patient records to enable end users to access critical patient information (such as patient identifiers and cardiopulmonary resuscitation status).
Engineering the risk It may be beneficial (observation)… … if the Acute Trust reviews the infrastructure and layout of the emergency department majors area in order to support the flow co-ordinator to reliably carry out their full responsibilities.
… if it was easier for trusts to find clear national guidance on what a good patient identification check looks like to assist the quality and consistency of trust guidance.
… if there was national guidance on the principles for good design of tools to support the critical task of patient identification.
… for healthcare organisations to provide guidance to support decisions in clinical areas that balance confidentiality and the visibility of critical patient information for patient safety.
… for healthcare organisations to assess their information technology infrastructure needs, such as equipment availability and network coverage, to enable staff to consistently access critical patient information.
Administrative and additional risk controls HSIB recommends that… … the Acute Trust explores the barriers to checking three identifiers when confirming a patient’s identification for their wristband, and takes appropriate action.
… the Acute Trust, in collaboration with the Ambulance Trust, develops and implements a formal emergency department booking-in policy.
… the Acute Trust tests its positive patient identification procedure for patients with dementia in order to identify risks and support the development of effective mitigating controls.
… the Office of the National Data Guardian supports local interpretation of the Caldicott Principles to give organisations and staff the confidence to display full patient names at the bedside to support correct patient identification for safer care.
… NHS England, during review of relevant Health Building Notes and Technical Memoranda, includes, as a consideration, that bedside patient information should be consistently visible.
Administrative and additional risk controls It may be beneficial (observation)… … if the Ambulance Trust develops mechanisms to capture the NHS number at the point of initial contact.
… if the Ambulance Trust adjusts its call audit tool to assess whether patient identification is correctly confirmed.
… if the risks associated with patient identification in an outpatient department are considered within staff education and in the procurement and implementation of technical systems.
Adherence to risk controls None

6.5 Review of the literature

Review articles included in the literature review

  • Boyd et al, 2018
  • Brenner et al, 2016
  • De Rezende et al, 2021
  • Emergency Care Research Institute (ECRI), 2016
  • Ferguson et al, 2019
  • Hutton et al, 2021
  • Lichtner et al, 2010
  • Lippi et al, 2017
  • Riplinger et al, 2020
  • Sevdalis et al, 2009
  • Shah et al, 2016
  • Waruhari et al, 2017.

Themes Identified from the review articles, including cited key studies

Theme Findings Theme identification Key study
Wristband risks Missing – particularly in children and in neonatal, outpatient and perioperative settings De Rezende et al, 2021 Phillips et al, 2012
Wristband risks Prepared ahead of time – for elective admissions and attached to patient notes ECRI, 2016 Smith et al, 2011
Labelling risks Batched labelling – of multiple specimens at once, and centralised label printing ECRI, 2016 Schmidt et al, 2013
Design and use of technology Risks created by staff – two patient charts open simultaneously ECRI, 2016 Virginio and Ricarte, 2015
Design and use of technology Limited use – factors interfering with the performance of barcode technology ECRI, 2016 Härkänen et al, 2015
Design and use of technology Workarounds used – protocol design and mismatch between work as prescribed/work as done ECRI, 2016

ECRI, 2016
Danaher et al, 2011; Phipps et al, 2012
Design and use of technology Low-quality evidence – although most interventions led to a statistically significant reduction in patient misidentification, the quality of the evidence was considered low De Rezende et al, 2021 De Rezende et al, 2021
Reliability of identification procedures Rigour – the rigour of processes varied, and personal characteristics were found to be used to identify patients Lichtner et al, 2010 Cohen et al, 2012
Reliability of identification procedures Accuracy – inaccurate and incomplete information Sevdalis et al, 2009 Sevdalis et al, 2009
Contextual factors Several factors influence misidentification – such as the patient’s time of presentation and presenting complaint, and staff fatigue and distraction Lichtner et al, 2010 Virginio and Ricarte, 2015