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Increasing the awareness of patient misidentification.

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VOL: 102, ISSUE: 05, PAGE NO: 23

Tracey Courtney, DipHE, is staff nurse vascular surgery, the Royal Devon and Exeter NHS Foundation Trust

The National Patient Safety Agency (NPSA) reported last year that it had been notified of 236 critical incidents involving problems with patient identification wristbands between November 2003 and July 2005 (NPSA, 2005). Patients who have communication barriers, such as those for whom English is not their first language, are the patients most at risk (Human Reliability, 2003).

The National Patient Safety Agency (NPSA) reported last year that it had been notified of 236 critical incidents involving problems with patient identification wristbands between November 2003 and July 2005 (NPSA, 2005). Patients who have communication barriers, such as those for whom English is not their first language, are the patients most at risk (Human Reliability, 2003).

Advice has been issued by the NPSA on the prompt use of identification bands following admission to hospital (NPSA, 2005) and this has highlighted clear lines of responsibility regarding the correct identification of patients. Nurses must ensure that at all stages of care patients have a clear and correct identification band in situ, as misidentification could lead to the wrong treatment being given and even death (O'Dowd, 2005).

A case of misidentification
Beyea (2002) described how the misidentification of a patient led to an unnecessary invasive cardiac procedure. During this patient's treatment there were 17 occasions when, as part of assessment by various health care professionals, identification should have been verified and unfortunately was not.

The patient reported trying to alert health care professionals but unfortunately they did not listen. This failure to listen to the patient was coupled with a failure to check their wristband.

This incident highlights the fact that health care professionals do not check patient identification wristbands frequently enough, often relying on familiarity with the patient. Beyea (2002) concluded that in this particular incident perioperative staff could be held accountable for not ensuring that the patient had correct identification wristbands in situ. This situation illustrates how, even within a routine area of health care, misidentification can occur.

Emergency services
There are other areas of health care practice where misidentification can pose a risk. One that has come to my attention is handover from ambulance crews to A&E departments.

Until 1970 ambulances were merely used to carry patients to a hospital. But now highly trained paramedics give a variety of emergency treatments including drugs, and ambulances have become an important element of health care delivery.

En route to the emergency department the patient's details are recorded on a handover sheet. These include medical history, time of arrival at the scene, the type of call, and any drugs administered. On arrival at A&E it is common practice for ambulance personnel to wait until the patient has been handed over to a member of staff. They then take the patient to a designated cubicle, ensure she or he is comfortable and then leave.

If a number of patients are arriving at the same time by ambulance, the paramedics await their turn to hand over the patient. When staffing levels are low and the department is busy, however, patients can be left without a wristband until a nurse is able to clerk them in.

After the patient has been handed over to A&E, the ambulance personnel's responsibility ends. At this point, until the patient has been clerked, there is nothing other than verbal communication to link the patient to their correct handover sheet.

This is a situation where a misidentification incident could occur and therefore nurses should be cautious, especially with patients who are unable to identify themselves.

Partnership working
The report by George Alberti, Transforming Emergency Care in England (DoH, 2004), recognised that changes in emergency care and the establishment of ambulance trusts have improved patient care. The experience of patients, carers and staff has been improved by setting a target of reducing the time between admission to A&E and departure to four hours.

This improvement in waiting times has allowed ambulance personnel to transfer patients more quickly, freeing them up so they can return to the next call.

In Alberti's report, Peter Bradley, national ambulance adviser and chief executive of London Ambulance Service, said: 'Ambulance trusts working closely with other care services now provide tailored care to meet the need of a wide range of patients they see. The current ambulance review will ensure that the ambulance service continues to be at the centre of providing high-quality care to patients.'

In 1995 the Audit Commission's report Setting the Record Straight - A Study of Hospital Records recommended that action be taken to improve the standard of record keeping. One key issue to be addressed was the lack of record sharing between health professionals and different work units. The report highlighted the need for records to be legible, up to date, relevant, put where they can be easily found and shared across domains without breaches of confidentiality.

A new partnership to help modernise ambulance services and improve the patient's journey through the health service, the Improvement Partnership for Ambulance Services (IPAS), was launched in 2003. The government agreed to invest £1m to improve and spread good practice. It is recognised that ambulance services have played a part in modernising the NHS - but few initiatives have supported them to modernise themselves.

IPAS wants to ensure that ambulance trusts continue to provide best practice. Its aim is to improve integration between services, breaking down the traditional boundaries between ambulance services and the wider NHS. It will ensure that there is better focus on ambulance trusts' delivery of The NHS Plan (DoH, 2000a).

IPAS has four main streams of work, one of them being to share and develop good practice. Spreading good practice and further integrating ambulance services within local emergency care networks and the NHS can achieve these targets (DoH, 2003a).

IPAS is in the process of developing clinical indicators to measure progress. As an 'organisation with a memory' (DoH, 2000b), it aims to reduce serious errors in the use of prescribed drugs by 40 per cent by 2005.

One of the organisation's targets is to implement changes in care practices that could reduce risk and improve patient safety (DoH, 2003b).

Reducing risk
Partnership working could also be used in risk management to reduce misidentification incidents. The number of patients at risk of being treated without identification bands could be reduced if ambulance services placed handwritten name bands on patients who are carried in the ambulance to emergency departments. This would ensure that the correct handover accompanies the patient into the emergency department. It would also give accurate documentation about the patient's medical needs and a clear link to the handover sheet that documents any drugs administered in the ambulance en route to the emergency department.

This will give emergency nursing staff clear identification for the patient and will ensure that there is no confusion over the provision of medical care.

This system has been suggested to the Royal Devon and Exeter NHS Foundation Trust emergency department and its local ambulance trust, which agrees that this action could make a significant contribution to reducing patient misidentification.

This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see

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