Waiting room blunder sees woman undergo invasive surgery instead of fertility treatment

A report calls for more to be done to prevent NHS waiting-room mix-ups. Credit: PA Wire/PA Images

More must be done to prevent waiting-room mix-ups, a watchdog has said after a patient received the wrong procedure when a similar name was called out across an NHS waiting-room.

The Healthcare Safety Investigation Branch (HSIB) said a better system of safety measures is needed to make sure patients are not mixed up and given the wrong invasive procedure during outpatient appointments.

It comes after a 39-year-old women received a colposcopy meant for another patient instead of the fertility treatment assessment she was meant to have.

HSIB said the misidentification happened when the patient was called through from the waiting room.

The patients had similar sounding names, HSIB said.

No other checks were conducted to check the woman’s identity before she was given the colposcopy – a procedure used to look at the cervix.

The error was only realised after the patient left, HSIB said.

While the mistake was raised quickly, and all members of staff apologised to the woman, she was so distressed that she decided not to continue with her fertility treatment, the HSIB report states.

“The experience had created considerable distress and that as a result she no longer wished to pursue fertility treatment,” the authors wrote.

HSIB said the incident was “not isolated” but this type of event is not widely reported.

“The task of calling a patient through for an outpatient appointment presents as a safety issue and contributes to the risk of an unintended patient being selected,” a new HSIB report states.

It has called for the NHS to review patient identification schemes in outpatient settings.

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.

“This report emphasises the current barriers in place to prevent these incidents are not strong or systemic.

“We have set out detailed analysis and learning for those working in outpatient settings across the NHS.

“The safety recommendation we have made is there to encourage cohesive and effective changes at a national level, to reduce the risk of misidentification, and ensure the right patient receives the right procedure.”

A spokeswoman for the NHS in England said: “These events are fortunately extremely rare and the NHS is currently undertaking its own review of incidents as hospitals rightly continue to prioritise patient safety.”