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Risk of associating ECG records with wrong patients
ECGs are routinely performed to diagnose cardiac problems and there are no risks associated with the test itself, however, there is a risk of associating ECG records with wrong patients leading 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.