NHS England responds to HSSIB report on positive patient identification

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The NHS England National Patient Safety Team has responded to a recommendation made in the Health Services Safety Investigation Body’s (HSSIB) National learning report: Positive patient identification, which was published in February 2024.

The report reiterated that the misidentification of patients remains a persistent safety risk across the NHS but is one that is under-recognised and under-researched. It made three safety recommendations to CQC and NHS England.

NHS England’s Digital Clinical Safety Team, within the National Patient Safety Team, has responded to the recommendation ‘HSSIB recommends that NHS England reviews and identifies system-wide requirements for scanning in positive patient identification. This is to support local organisations to use scanning technology to reduce misidentification incidents’, with the following:

As described in the HSSIB report, Scan4Safety enables products and people to be tracked through the supply chain and across hospitals. Scan4Safety was first introduced in 2016 as a pilot funded by the Department of Health to work with six demonstrator sites to investigate how consistent use of point of care scanning might improve efficiency and safety within the NHS. Implementation requirements for adopting Scan4Safety (S4S) for positive patient identification were developed as part of this initial S4S work. The report ‘A Trust’s guide to positive patient identification’ can be accessed via the recently updated Scan4Safety website.

NHS England’s National Patient Safety Team (NPST) support the S4S programme by providing national advice, support and guidance to NHS organisations interested in adopting or improving approaches to ensure the traceability of medical devices and other products used in health and social services safely. The NPST recently updated the S4S website to help organisations find the resources they need to promote S4S locally. The website is supported by GS1 and received input from other key stakeholders. The NPST have also launched an interactive NHS Futures page with more hands-on tools for providers to use locally.

To further our support to the system, the NPST work closely with other national organisations (MHRA, NHS Supply Chain and GS1), people who use services and NHS trusts in line with system requirements to increase the uptake of safe and effective scanning technologies.

The team is currently reviewing the strategic direction of the S4S support offering and the potential to scale and spread the use of scanning technology to improve patient safety including reducing patient misidentification.

Action planned to deliver safety recommendation:

  • Review strategic aims of the S4S support offered by the national team to ensure workstream is delivering impactful scale and spread of the use of scanning technology to improve patient safety. This will include an emphasis on patient misidentification. By March 2025.