The exterior front entrance of a hospital emergency department, with ambulances parked outside.

Local integrated investigation pilot 1: Incorrect patient identification

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Background

Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.

Themes

The pilot published three investigations focused on cross-boundary and multi-agency safety events.

This is the first pilot investigation.

The other pilot investigations are:

Report summary

The Patient (Patient 1), a woman aged 75 years, was taken to an emergency department (ED) by ambulance in April 2021. This followed a 999 call from Patient 1’s Granddaughter to the emergency operations centre. The emergency operations centre used the wrong NHS number for Patient 1. They used the NHS number of another individual (Patient 2), who had the same date of birth as Patient 1 and a similar name.

On arrival in the ED, Patient 1 was booked in under Patient 2’s NHS number. This NHS number continued to be used during Patient 1’s time in hospital. Initially, Patient 1 received medication prescribed by an ED doctor, based on her own supply brought in by her family. Following a pharmacy review on day 7 of admission, the medications were changed to those taken by Patient 2.

The Patient declined to take the incorrect medication; it was unclear why. The error was identified by a pharmacist the following day as an incidental observation of an unfamiliar medication.

The investigation focused on the key communication points in Patient 1’s care pathway where details of the Patient’s identification were handed over. The systems and processes in place with each provider (that is, the Ambulance Trust and the Acute Trust), including their local practices and guidance, were reviewed.