NHS blunder sees wrong woman given invasive procedure

A woman was given an invasive gynaecological procedure instead of fertility treatment after she was wrongly identified as another patient, a safety report says.

The error was one of 472 serious healthcare incidents reported in England between 2019 and 2020.

The Healthcare Safety Investigation Branch (HSIB) says such cases can lead to physical and psychological harm.

It says changes are needed to make sure they don’t happen.

The mix-up happened in an outpatient clinic where patients go for consultations, tests and procedures – but do not stay overnight.

Visits to these types of clinics have nearly doubled in the past decade, says the HSIB, who investigated the incident.

Nearly half of the serious incidents reported between April 2019 and the end of March 2020 were procedures performed on the wrong patient or on the wrong part of the body, its report says.

“The patient told us she was so distressed after the incident that she did not
want to pursue her fertility treatment.”

Mistaken identity

The 39-year old woman visited a gynaecology outpatient department for her first fertility appointment in July 2019, with her sister.

She was checked in at the reception desk at the same time as another patient, who had arrived for a colposcopy appointment. This is a procedure to look at the cervix, the lower part of the womb at the top of the vagina, often carried out if cervical screening finds abnormal cells in the cervix.

The nurse called out the second patient’s name several times with no response and then just her first name.

The first patient, whose surname sounded similar, thought the nurse was calling for her and was led into the clinic room.

After a number of further misunderstandings which failed to pick up the error, the woman was wrongly given the invasive procedure and left the clinic, only to be phoned on her way home and told what had happened.

Staff apologised and the patient eventually went on to have her fertility appointment.

Lack of safety controls

“The patient told us she was so distressed after the incident that she did not want to pursue her fertility treatment,” said Dr Sean Weaver, deputy medical director at HSIB.

He added: “Any invasive procedure carried out incorrectly has the potential to lead to serious physical and psychological harm and erode trust in the NHS.”

Dr Weaver said the number of invasive procedures carried out in outpatient settings was rising, and there were no strong barriers in place to stop “misidentification” incidents happening.

At present, the report says there are no formal safety controls to manage the risks that can arise when patients have similar names and several clinics are running at the same time in a department.

With many patients waiting in the same area, this can “affect the risk of the wrong patient being selected”, it said.

It says factors such as workloads and time pressures on staff may affect the level of safety checks carried out.

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