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An NHS England patient safety alert has been issued today (4 March 2014) to all NHS services in England that use ECG machines to diagnose cardiac problems. The alert highlights the risk of printing the wrong patient’s ECG records in error, which could lead to misdiagnosis and incorrect treatment.
The alert has been issued following a recently reported patient safety incident where the ‘copy’ button had been pressed on the ECG machine in error instead of the ‘auto/start’ button. This resulted in a copy of the previous patients’ ECG results being re-printed; staff did not immediately realise the error and labelled the ECG record incorrectly with the new patient’s identifiers. As a result, the patient underwent an unnecessary procedure and had a further complication.
The NHS England Patient Safety Domain identified 17 previous incidents reported from across the country since January 2008, describing occasions where the ECG of a previous patient was re-printed; none of these additional incidents resulted in harm to the patient.
Dr Mike Durkin, NHS England Director of Patient Safety, said: “Patient safety alerts are a crucial part of our work to rapidly alert the healthcare system to risks and to provide guidance on preventing potential incidents that may lead to harm or death.
“We use data on patient safety incidents reported by healthcare providers to identify themes and patterns of similar incidents across the country. Even if these incidents are extremely rare, if there is a risk to the safety of patients, we will alert all relevant providers to ensure appropriate action is taken to eliminate the possibility of a similar incident occurring. This signals my intention to move from the current approach of risk management and mitigation to a system that recognises a determination to not only evaluate all patient safety risks but to work with intent to eradicate all causes of such risk.”
You can view the full Patient safety alert on risk of associating ECG records with wrong patients here.