Safer patient identification Right patient right care

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Safer patient identificationRight patient
right care

• Chris Ranger
• Head of Safer Practice

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What is the impact of errors in healthcare?

• Each year
• 10 of inpatient episodes in the UK result in
  error
• 850,000 of the 8 million hospital admissions in
  England result in error
• 2 billion is spent in England on extra days in
  hospital
• A significant proportion are patient
  identification errors

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Patient Safety a global issue
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What goes wrong in matching patients with care?

• Patient is given the wrong treatment because
  samples, specimens or x-rays arent matched with
  the right patient
• Patient is wrongly identified and gets treatment
  intended for another patient
• Patient is given the wrong treatment because of
  failures in communication or checking

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What has the NPSA done about mismatching?

• Commissioned two studies - one on manual checking
  and one on matching with technologies
• Right patient - right care summary document and
  framework for action published 9th December 04
• Full reports of commissioned work available on
  our website www.npsa.nhs.uk

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What are the findings on manual checking and
mismatching?

• Bedside checking is a major source of errors in
  matching patients with care
• There is a high rate of missing patient
  wristbands
• Manual checking processes are not being formally
  risk assessed

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What are the findings on technologies and
mismatching?

• No single technology meets all the requirements
• Barcoding is currently the best technology for
  avoiding mismatching but RFID is potentially a
  more powerful tool
• A mix of technologies may be best - different
  mixes for different areas of care

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Are technologies sufficient on their own?

• People use technology - it must be usable,
  efficient and hard to override
• Technology should confirm/validate manual checks
  -NHS staff are still responsible for checking
• How technology is implemented is as important as
  the technology itself

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What about Connecting for Health (NPfIT) and
Informing Healthcare?

• NPSA is working with CfH to ensure that any
  technological solutions to mismatching are
  consistent with the programme both nationally and
  locally
• Nationally Safety Officer seconded from the
  NPSA
• Locally working with Local Service Providers on
  safety solutions
• In regular contact with Informing Healthcare,
  Wales

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What next? - general

• NPSA will help the NHS, healthcare industry and
  patients work together to devise and introduce
  systems to help prevent mismatching
• NPSA is monitoring advances in initiatives and
  solutions to prevent mismatching details to
  rightpatient_rightcare_at_npsa.nhs.uk

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What next? Blood safety

• Blood transfusion safety - Delivery of a national
  standard specification for IT tracking systems
  endorsed by CfH
• Recommendations to the NHS based on testing and
  development of other potential solutions such as
  photo-ID and better staff training

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What next? Patient ID

• NPSA programme on Safer Patient ID
• Patient Safety Alert on wristband wearing in
  acute settingsSept/Oct 05
• Standardising wristband design across the NHS
• Information standard (ISB) on patient identifiers

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Safer patient identification

• Opportunity for questions
• Email enquiries to chris.ranger_at_npsa.nhs.uk