A safety report has found a 39 year old woman was given an invasive gynaecological procedure instead of fertility treatment after she was wrongly identified as another patient.
This was one of 472 serious healthcare incidents reported in England between 2019 and 2020. The Healthcare Safety Investigation Branch (HSIB) says such cases can lead to physical and psychological harm, saying changes are needed to make sure they don't happen.
The patient was checked in at the reception desk at the same time as another patient, who had arrived for a colposcopy appointment. A nurse called out the second patient's name several times with no response and then just her first name. The first patient, whose surname sounded similar, thought the nurse was calling for her and was led into the clinic room. Only after the procedure took place and the patient was on her way home, she received a phone call and told what had happened, staff apologised and the patient eventually went on to have her fertility appointment.
The patient was so distressed after this incident, she did not want to continue with 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” said Dr Sean Weaver, deputy medical director at HSIB. At present, the report says there are no formal safety controls to manage the risks that can arise when patients have similar names and several clinics are running at the same time in a department. It says factors such as workloads and time pressures on staff may affect the level of safety checks carried out.
Co-head of our Medical Negligence team, Stuart Bramley, commented, “Incidents such as this are known as ‘never events’ precisely because they should never happen. Although there was no physical injury, the emotional distress for the patient concerned must have been dreadful and it is only a relief that she was not mistaken for someone booked in for surgery rather than an investigation.
The BBC article refers to the Health Service Investigation Board expressing concern that there are no strong barriers in place to avoid misidentification of patients occurring. In fact there are – anyone who has visited a hospital or GP surgery recently will know that various checks are taken to confirm that the individual is indeed the correct patient. Here, it seems that although the wrong person was only called by her first name, which should never happen, there were then ‘a number of further misunderstandings which failed to pick up the error’. That is not a failed system but human failing and it is difficult to see how that can be completely prevented. I do hope those at the hospital concerned learn the lessons here”.
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