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.

Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS).

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.

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