ACTION TO PREVENT MISMATCHING PATIENTS WITH CARE MUST INVOLVE MANUAL CHECKING & NEW TECHNOLOGIES
14 December 2004 - Cambridge Consultants

The findings from the Cambridge Consultants study have been published in a report titled 'Right patient, right care'. The report highlights the areas where technological advances can be harnessed to ensure that patient identities are not confused and that each patient receives the medication and care intended for them. It also points to significant opportunities to enhance patient safety by working with the National Programme for IT to ensure that new technologies such as barcoding, radio frequency tagging and biometrics such as fingerprinting are compatible with it both nationally and locally.

The NPSA is continuing to monitor advances in this field and is interested to hear from anyone developing initiatives or solutions. 'We will share information and also promote exchanges between interested parties,' said Chris Ranger, NPSA's Head of Safer Practice.

International research has identified the problem of mismatching patients with aspects of care, which can include confusing one patient with another, or mismatching medication, blood or pathology samples. Where mismatching happens in surgery, the patient may have the wrong part of their body operated on or removed. Mismatching can result in serious, lasting harm such as chronic pain, undiagnosed cancers, blindness and even death.

Cambridge Consultants was asked to investigate and research the technologies that could be used and found that there is no single solution to improve patient matching. In some instances a mix of technologies will be appropriate. It also concluded that the application of technology in the health service is likely to change over time with developing technology and changes in public acceptance.

The introduction of new technology can itself create problems and lead to failures and accidents if the analysis, design, management and evaluation fail to take account of the interface between people and technology.

The report also cautions that it is vital to get simple manual checks right as well. The NPSA commissioned research on manual checking from Human Reliability Associates of Dalton, Lancashire. This confirmed that mismatching was a significant area of concern. Manual checking processes have rarely, if ever, been subject to formal risk assessment or systematic research.

The research found:

bedside identity checking, the final opportunity to pick up any errors, appears to be a major source of matching errors;

the high rate of hospital in-patients' wristbands going missing is a potential obstacle for the use of automated identification methods such as barcodes;

the tendency for patients not to be asked their name increases the risk of errors;

double independent checking for high risk tasks, as used in the airline industry, is not used in the health service.

The NPSA is currently working on safer patient identification such as wrist band identification and checking procedures. These will be communicated with the whole health service and other interested parties such as the healthcare industry when ways of avoiding mismatching errors are developed further. It is vital that the health service works with the technology manufacturers to develop solutions tailor-made for health service settings.

Chris Ranger said: 'There are many examples of technology being used in imaginative ways, for instance to match patients and blood samples using barcodes, check patients' identities in operating theatres or allow patients secure access to their notes in a GP surgery by using fingerprints . But this work has shown that improving manual checking procedures is also a priority to prevent errors that can lead to serious patient harm.'

Matthew Allen, a senior consultant at Cambridge Consultants commented: 'Our research concluded that in this environment the reliability of technology is critically dependent on how well it is implemented. Whilst various technologies could be used for improving patient matching, none at present will be truly effective without pre-emptive programmes to get buy in from patients and professionals.'

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