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472 serious healthcare incidents reported in England between 2019 - 2020
A recent safety report into serious healthcare incidents in the NHS found that 472 incidents were reported in England between 2019 and 2020, including one in which a woman was given an invasive gynaecological procedure instead of fertility treatment after she was wrongly identified as another patient.
According to the Healthcare Safety Investigation Branch (HSIB), such cases can lead to physical and psychological harm and changes are needed to make sure they don't happen going forward.
Almost half of the serious incidents reported between April 2019 and the end of March 2020 involved procedures performed on the wrong patient or on the wrong part of the body.
In the above case, a 39-year-old woman visited a gynaecology outpatient department for her first fertility appointment in July 2019. The woman was checked in at the reception desk at the same time as another patient, who had arrived for a colposcopy appointment.
A colposcopy is a procedure to look at the cervix, the lower part of the womb at the top of the vagina, which is often carried out if cervical screening finds abnormal cells in the cervix.
A nurse called out one of the women’s full names but got no response, after then calling just the patient’s first name, the other woman - whose surname sounded similar - thought the nurse was calling for her and was led into the clinic room.
Following several further misunderstandings which failed to pick up the error, the woman was wrongly given the invasive procedure, only to be phoned on her way home from the clinic and told what had happened. Staff apologised and the woman eventually went on to have her fertility appointment.
No safety controls
Dr Sean Weaver, deputy medical director at HSIB said: “The patient told us she was so distressed after the incident that she did not want to pursue her fertility treatment.
"Any invasive procedure carried out incorrectly has the potential to lead to serious physical and psychological harm and erode trust in the NHS."
Dr Weaver added the number of invasive procedures carried out in outpatient settings was on the rise, and there were no strong barriers in place to stop "misidentification" incidents occurring.
The HSIB’s report says there are currently no formal safety controls in place to manage the risks that can arise when patients have similar names, and several clinics are running at the same time in one department. It said that many patients waiting in the same area can "affect the risk of the wrong patient being selected". Factors such as workloads and time pressures on staff may affect the level of safety checks carried out, say the HSIB.
Lesley Herbertson, Partner in our Clinical Negligence team, comments:
"This extract from the HSIB’s safety report for the period April 2019 to March 2020 makes troubling reading. The errors highlighted are fundamental and it is shocking that in our 21st century healthcare service it is possible to misidentify patients.
"Double checking of names, addresses, dates of birth and the like have been standard practice for many years. So problems presumably arise due to a failure on the part of staff to perform these basic checks. Time pressures and workloads are given as explanations or excuses for these oversights. However, a routine double-check takes less than one second whilst sorting out a mistake caused by a failure to check may well absorb significantly more precious time and resources."