On the road to improving safety

Between February 2006 and January 2007, the National Patient Safety Agency (NPSA) received over 24,000 reports of patients being wrongly identified and mismatched with their care. Reducing and, where possible, eliminating these misidentification errors is central to improving patient safety. Although many of these errors result in little or no harm, they can be distressing for both patients and for the staff involved. Some of these adverse incidents, however, can result in serious, lasting harm – such as chronic pain, undiagnosed cancers and, in the case of some blood transfusion errors, even fatalities. The use of hospital wristbands as a means of positive identification is recognised as a key factor in preventing adverse incidents to patients, but more still needs to be done to improve their effectiveness. Despite the fact that the use of hospital wristbands are a common feature of the protocols of most hospitals to ensure patients receive the correct treatment and medication intended for them, serious incidents are still occurring. Of the 24,000 or so misidentification reports received by the NPSA it was estimated that more than 2,900 of these related to wristbands and their use. As a result of this data and following consultations with patients and healthcare staff, the NPSA has concluded that standardising the design of patient wristbands, the information on them and the processes used to produce and check them will ultimately improve patient safety. This led to the NPSA, in July 2007, issuing its “Safer Practice Notice”, Standardising wristbands improves patient safety, to all NHS organisations in England and Wales. The Safer Practice Notice recommended that action was required to standardise wristbands across the NHS by July 2008, with a final clause stating that NHS organisations must be able to generate and print all patient wristbands from hospital demographic systems such as PAS (Patient Administration System) by July 2009. Furthermore, the NPSA, together with NHS Connecting for Health, has recently issued a further Safer Practice Notice which recommends that the NHS number is now used as the national unique patient identifier by September 2009. This is aimed to prevent errors relating to patient’s local identification numbers involving duplications in the system which may result for example in two patients having the same number or one patient having more than one number with the obvious potential for confusion and risk.

Patient identification
Against this backdrop, Olympus UK – a healthcare company with a long tradition of improving patient safety – recently held a series of patient safety road shows for healthcare professionals, throughout the UK, aimed at highlighting how innovative, high-tech solutions were now available to help achieve the NPSA’s recommendations. During the Birmingham Patient Safety Roadshow, identification problems caused by similarly named patients and duplicate records on hospital data systems were examined in detail by consultant haematologist and lead consultant for blood transfusion, Dr David Cummins of the Royal Brompton and Harefield NHS Trust. In his presentation: Patient identification: one patient or two?, Dr Cummins outlined that a fundamental requirement to safe blood transfusion and patient medication is accurate patient identification. Dr Cummins feared, however, that some adverse events may occur as a result of the confusion caused when patients have similar or even identical identifiers to another patient, a “doppelganger” as he described it, or when their details are wrongly derived from two or more patients, i.e. a “hybrid”. Multiple records for the same patient or “duplicates” were another problem, particularly if key information relating to special requirements for blood transfusion, allergies or other important personal details are not uniformly included in all records. Newborns and neonates were a particularly vulnerable category of patient who were always at risk of an identification error he claimed, they have the same or similar dates of birth, are found in adjacent cots, often have no identification numbers and, even worse, at birth all tend to be named “baby”. Furthermore, Dr Cummins also described how many serious transfusion errors involve what the Serious Hazards of Transfusion scheme, or “SHOT”, describe as “extraordinary co-incidences” of patients with similar or identical names. However, he believed that these instances are, in fact, not extraordinary, but more ordinary than we imagine, and because of this are “disasters waiting to happen”. Outpatients were a classic example of how mix-ups could occur as these patients often present for phlebotomy or other procedures without any wristbands at all. Dr Cummins also believed that the introduction of the NHS number as the unique patient identifier was long overdue and would go some way to resolving the problem of mix-ups involving local hospital numbers, particularly when patients are transferred between neighbouring hospital Trusts for treatment. He warned that clinicians should ask themselves the question: “Am I dealing with the correct patient?”

Remote control
A user experience followed next from Eithne Hughes, special practitioner of transfusion at Ysbyty Glan Clwyd Hospital, Wales, who, in her presentation: Blood on demand in North Wales, outlined the advantages and pitfalls of remote release of blood products on distant satellite hospitals from the main site itself. Remote or electronic release is a concept that comes into its own when one central blood bank serves two or more sites, particularly if one is geographically remotely situated. In these situations it is possible to perform all pre-transfusion compatibility testing on the main site and if all blood grouping safety criteria are met, release suitable blood for the patient on a different site. Unfortunately, as Eithne explained, the potential for transfusion errors and procedural mix-ups in these circumstances can be greater unless a robust IT-based system is incorporated into the blood bank’s procedures to safeguard against this. Eithne explained how the procurement and installation of an Olympus-based system in the main blood bank had paved the way to remote release on the other satellite hospitals. Advantages of the remote release system included offering a faster service to patients, being less dependent on transport, providing better blood stocks management with less wastage and an improved “cold chain”. Disadvantages were that a robust IT network was essential for the system to function smoothly, printer failures were a potential nightmare and that MHRA compliance required for all areas of the procedure to ensure full traceability of blood components. Eithne concluded that remote release had the potential to provide better services to patients as well as improve blood usage, but that a secure IT-based system was essential to ensure positive patient identification remained at the heart of the matter.