RCR welcomes HSIB report on preventing misidentification of outpatients

Thursday 3 June 2021

The RCR has welcomed a new safety report highlighting the risks of misidentifying outpatients scheduled for interventional procedures. 

Today (3 June), the Healthcare Safety Investigation Branch (HSIB) has released a report following an investigation into the risks involved in the correct identification of patients in outpatient settings

The national investigation was sparked by a reference case in which a woman who was attending a gynaecology clinic for a fertility appointment underwent a colposcopy procedure after being mistaken for another patient. 

The HSIB report highlights how communication gaps, staff workloads and poor NHS IT can all lead to the misidentification of outpatients, and recommends that NHS England should now conduct a review into the systemic risks and controls around the issue.

Commenting on the report, Dr Jai Patel, chair of the RCR’s Interventional Radiology Committee (IRC) said:

“The RCR and IRC are committed to initiatives aimed at enhancing patient safety and welcome the key recommendation of the HSIB report.”

Interventional radiology (IR) is a sub-specialty of radiology, where specially trained radiologists carry out minimally-invasive image-guided surgery. IR procedures can range from urgent life-saving techniques to remove stroke clots and stop internal bleeding, to important non-emergency surgery such as destroying cancerous tumours, clearing urinary obstructions and treating painful uterine fibroids. 

Dr Patel added:

“A significant majority of IR procedures are delivered in a day case or outpatient setting, making the HSIB report pertinent to IR practice. IR departments have already incorporated the World Health Organisation's surgical safety list into their practice and welcome any additional initiatives that improve patient safety further.  

“Correct patient identification is also relevant to diagnostic radiology, where large volumes of imaging examinations – some utilising ionising radiation – are performed on a daily basis in an outpatient setting.  

“The implementation of additional measures previously suggested by the UK’s Clinical Imaging Board, such as three-point confirmation of patient identification immediately prior to any imaging study, have also helped radiology departments to minimise the risk of wrong patient identification and ensure the process of ‘right test, right patient, right time’.”