SALG would like to highlight an HSSIB investigation of cases of mistaken patient identification, that contains recommendations relevant to anaesthetists and departments of anaesthesia.

On February 8th 2024, the Health Services Safety Investigations Body published a National Learning Report: Positive Patient Identification.  Positive patient identification is the term used for correct identification to ensure that the right patient receives their intended care such as diagnostic tests or treatments.  This is highly relevant to anaesthetists, who are often the last healthcare provider to confirm patient identification before anaesthesia is induced.

The Strategic Executive Information System contains 171 serious incidents over a 6-year period where harm occurred due to misidentification of patients undergoing surgery, having laboratory investigations or being prescribed medications.

The risk of misidentification increases during transfer of care – both at handovers and patient transfer between settings. Certain patient groups appear more at risk, for example the disabled or ethnic minorities whose naming conventions may be unfamiliar to their healthcare providers.

 The report noted that ‘technology alone is unlikely to reduce risk of misidentification’. Poorly designed environments and workspaces increased the risk. This report highlights the need for a safe workplace for anaesthetists to practice, with access to information technology systems at the bedside that minimise the risk of patient identification errors.  A simple example is the provision of handheld devices so electronic consent forms can be checked with patients on trolleys in anaesthetic rooms or theatres. Where laboratory investigations require a sample label to be electronically generated, the means to do so should be immediately available to those obtaining the sample.

SALG have offered NHS England any support that might be needed in implementing the recommendations of the report.

Although not common practice, whenever possible the NHS identification number rather than the Trust MRN should be used. The former is unique to each patient, but a single patient may have more than 1 MRN.