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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 3/4/2014 12:00:00 AM
Organization: NHS Commissioning Board
This alert discusses the patient safety incidents that can occur when ECG records are associated with the wrong patient. A total of 18 incidents were reported; one is described in detail. In one case, the ‘copy’ button had been pressed instead of the ‘auto/ start’ button in error, resulting in a copy of the previous patient’s ECG being re-printed. Staff did not immediately realise the error and labelled the ECG record incorrectly with the new patient’s identifiers. The patient underwent an unnecessary procedure and had a further complication as a result. In the 17 other cases, causes were established in some cases and described as accidentally pressing the copy button (seven incidents) and not following user instructions (two incidents). Contributing factors leading to these incidents included the following: • Patient identifier - the default setting did not include the need to enter patient’s identification details before being allowed to continue with the tracing. • Poor design - the copy button and the ECG trace button are situated directly adjacent to one another on some ECG machines. • Staff awareness - staff were unaware of the existence of the copy button and failed to follow user instructions correctly. Recommendations to prevent similar patient safety incidents are provided.

Additional Details

Device:
ECG machine

Communication
  1. Disseminate this Alert to all nursing, medical and engineering staff who are using or maintaining ECG machines.
  2. Share any learning from local investigations or locally developed good practice resources by emailing: patientsafety.enquiries@nhs.net
Rules / Policies / Procedures
  1. Establish if there is a risk of associating ECG records with wrong patients in your services and if similar incidents have occurred.
  2. Consider if immediate action needs to be taken locally and develop an action plan, if required, to reduce the risk of a similar incident occurring.

Risk of associating ECG records with wrong patients