NHS gives wrong treatment to 500 hospital patients a week

Hospital staff gave the wrong treatment to the wrong patient on almost 25,000 occasions last year, leading to deaths, serious injury and long-term harm, official figures show. Errors in identifying patients led to at least 500 a week getting the wrong operation the wrong drugs or diagnostic tests, the National Patient Safety Agency said.

No breakdown of the figures was available yesterday to show how many had died or been seriously harmed and how many escaped injury. The agency admitted the total could be much higher because many incidents went unreported.

Almost 3,000 of the incidents are estimated to have occurred because of confusion over wristbands used to identify patients. An investigation found that the colour red on a wristband had eight different meanings in different NHS trusts, ranging from "allergic to penicillin" to "does not have English as a first language".

The agency issued a warning notice to all NHS trusts urging them to take "immediate action" to produce a standard wristband. It set a deadline of July 2008 for its introduction. The wristband will be white and carry the last name of the patient followed by the first name, date of birth and NHS number. Only one other colour - red - will be permitted, to indicate patients at high risk.

Christine Ranger, head of safer practice at the agency, said there were 24,382 incidents between February 2006 and January 2007 in which patients were "mismatched with their care." Of these more than 2,900 related to wristbands and their use. "These are causing patients to have the wrong operation, the wrong [blood] transfusion, the wrong medication or the wrong diagnostic test," she said. "Some incidents will involve significant harm and some have led to deaths."

People with common names such as Smith or Patel were at particular risk. Mistakes also happened when staff relied on first names, Ms Ranger said. "In one case a nurse on a ward for the elderly came looking for a patient called Elsie to take a blood sample for a transfusion. There were two Elsies on the ward and the sample was taken from one while the transfusion was intended for the other. That very nearly led to a serious incident."

Last year, the NPSA reported 41,000 medication errors between July 2005 to July 2006, which caused 36 deaths. A further 2,000 patients suffered "moderate or severe harm." In 2005, the National Audit Office reported that nearly one million errors or safety lapses had occurred in the previous year, causing 2,000 deaths. Half of the incidents could have been avoided if staff had learnt from past mistakes.

Unreported NHS figures

The disclosure that thousands of NHS patients are being wrongly identified only emerged yesterday after it was reported in Nursing Standard.

The NPSA said it issued a press release containing the figures last week, but had only circulated it to the trade press.

The shadow Health Secretary, Andrew Lansley, said the agency had to create a culture in the NHS where reporting what went wrong was 'everybody's business'.

'If we expect individuals on the front line never to cover up then surely it is the role of the NPSA to give the greatest possible exposure to the level of errors, not to shock but to ensure we are not going to have a culture that hides anything.'

A spokeswoman for the NPSA said: 'The decision was taken that this was not a big enough story for the national press. It may not have been a brilliant judgement on our part, but there was no attempt to bury bad news.'

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