NHS mix-up led to female patient having unnecessary cervical examination

Patient was left so distressed after incident she decided ‘not to pursue fertility treatment’

A patient was given an unnecessary procedure after an identification error (PA)

A woman was subjected to an unnecessary invasive procedure in an NHS outpatient clinic after she was confused for another patient, a safety watchdog has found.

The Healthcare Safety Investigation Branch has called for a review of how the NHS can avoid the mishap happening again after investigating the case of a 39-year-old woman who was subjected to an unnecessary cervical examination.

HSIB said a better system was needed as the number of outpatient appointments has increased from 54 million to 94 million during the last 10 years with many clinics carrying out more invasive procedures.

According to its latest investigation, the female patient was attending a gynaecological outpatient clinic for a fertility treatment assessment.

The error happened when she was called through from the waiting room as another patient had a similar sounding name.

No other checks were done to confirm her identity and she underwent a colposcopy, an examination of the cervix, the lower part of the womb and top of the vagina.

The error was only realised after the patient had left.

HSIB said the incident was not isolated but there was a lack of data of the scale and impact of patient misidentification especially in outpatient settings.

It was classed as a wrong site surgery and HSIB said between April 2019 and March 2020 there were a total of 226 incidents reported as wrong site surgeries.

Dr Sean Weaver, deputy medical director at HSIB said: “Any invasive procedure carried out incorrectly has the potential to lead to serious physical and psychological harm and erode trust in the NHS. In our case, the patient told us she was so distressed after the incident that she did not want to pursue her fertility treatment.

“It was important to explore this patient safety risk at the system level, especially as invasive procedures being done in outpatient settings continue to increase, even without any changes that might be brought about due to the Covid pandemic.”

HSIB identified risks of mistakes happening including a reliance on verbal communication which can be affected by noise and the patient’s emotional state.

It also said operating multiple clinics with only one waiting room for all patients might increase the chances of the wrong patient being treated, as well as time pressures on staff.

It also highlighted the lack of technology to use the NHS number as a way of identifying patients and said outpatient departments often lack integrated computer systems.

HSIB called on NHS England to review the risks of patient identification in outpatient clinics and how checks could be put in place. It also recommended reviewing whether the NHS number for patients could be adapted to guard against misidentification.