Waiting room mix-up sees wrong woman given invasive procedure
3 June 2021, 09:59
A patient was given the wrong procedure when a similar name was called out in an NHS waiting room, according to a report.
The 39-year-old woman received a colposcopy intended for someone else instead of the fertility treatment assessment she was supposed to have.
Aside from the name, no other checks were carried out to verify the woman's identity, and the mistake was only realised once the patient left, said the Healthcare Safety Investigation Branch (HSIB).
As a result, the HSIB has called for a better system to be in put in place to prevent a similar mix up in the future.
They have suggested the NHS review patient identification schemes in outpatient settings.
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Deputy medical director at HSIB, Dr Sean Weaver, said: "Any invasive procedure carried out incorrectly has the potential to lead to serious physical and psychological harm and erode trust in the NHS.
"In our case, the patient told us she was so distressed after the incident that she did not want to pursue her fertility treatment.
"It was important to explore this patient safety risk at the system level, especially as invasive procedures being done in outpatient settings continue to increase, even without any changes that might be brought about due to the Covid pandemic.
"This report emphasises the current barriers in place to prevent these incidents are not strong or systemic.
"We have set out detailed analysis and learning for those working in outpatient settings across the NHS.
"The safety recommendation we have made is there to encourage cohesive and effective changes at a national level, to reduce the risk of misidentification, and ensure the right patient receives the right procedure."
A spokeswoman for the NHS in England said: "These events are fortunately extremely rare and the NHS is currently undertaking its own review of incidents as hospitals rightly continue to prioritise patient safety."
