Cambridge Consultants - Action to prevent mismatching patients with care must involve manual checking and new technologies

Action to prevent mismatching patients with care must involve manual checking and new technologies

Patient Mismatching Cambridge Consultants has delivered its report to the National Patient Safety Agency (NPSA) identifying new developments in technology that could prevent the mismatching of patients with appropriate care. The report, as part of a wider study by the NPSA, will help to focus the health service on new technological developments and improve manual checking processes.

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 (NPfIT) 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. Those wishing to contribute should email:

rightpatient_rightcare@npsa.nhs.uk.

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."

The report is available at www.npsa.nhs.uk/health/publications. Printed copies can be requested by calling 08701 555455.

Case studies are available from Alison Pitts-Bland, Head of Media & Parliamentary Affairs, National Patient Safety Agency on 0207 927 9500.

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Note to editors

National Patient Safety Agency
The National Patient Safety Agency (NPSA) was established in July 2001 following the recommendations of the Chief Medical Officer’s report on patient safety, An Organisation with a Memory. The NPSA’s role is to improve the safety of NHS patients by promoting a culture of learning and reporting from patient safety incidents, and to manage the national reporting system to support this function.

By collecting and analysing data on patient safety incidents the Agency will be able to identify trends ands patterns of avoidable incidents, provide feedback to organisations to enable them to change their working practices, help develop models of good practice and systems solutions at national level and support ongoing education and learning.

Further information is available at www.npsa.nhs.uk

Cambridge Consultants has for over 40 years enabled its clients to turn business opportunities into commercial successes, whether launching first-to-market products, entering new markets or expanding existing markets through the introduction of new technologies. With a team of over 200 engineers, scientists and consultants, in offices in Cambridge (UK) and Boston (USA), we are able to offer solutions across a diverse range of industries including healthcare, industrial and consumer products, automotive, transport, energy and wireless communications.