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Fertility patient given wrong, invasive procedure

14 June 2021
Appeared in BioNews 1099

A fertility patient received an invasive procedure meant for another woman in an NHS waiting room mix-up, a safety report has said.

The patient received a colposcopy, a follow-up cervical screen procedure to identify abnormal cells in the cervix, instead of having her first fertility appointment. The patient checked into the outpatient clinic at the same time as the patient meant to undergo the colposcopy. The misidentification happened as the nurse called the second patient's name, but the fertility patient, whose name sounded similar, came forward and underwent the colposcopy. The patient was notified of the mistake after leaving the clinic.

'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,' Dr Sean Weaver, deputy medical director at the Healthcare Safety Investigation Branch (HSIB) said, which launched a national investigation following the case.

According to the investigation, 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.

Furthermore, the misidentification was not spotted when the patient went from the waiting room into the clinic room, which led to her undergoing the invasive procedure. In light of this, the HSIB has called for the NHS to review patient identification schemes in outpatient settings.

This incident was one of the 472 serious healthcare errors that were reported in England between 2019 and 2020. In the past ten years' outpatient clinics' appointments have doubled, yet research on patient safety is lacking and misidentification of patients is not widely reported. There was limited use of the unique NHS identification number and usually no physical means by which NHS staff can identify outpatients, the HSIB report noted.

A spokesperson for NHS England commented that '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.'

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