About Confusions

Scenario:

Two patients were linked to the same NHS number on PDS due to the patient’s having very similar identification details.

Patient Profiles

• Patient A: Mr. Patient, born 12 March 1985, lives in Birmingham, registered at Practice A.
• Patient B: Mr. Patient, born 12 March 1985, recently moved to Manchester, registering at Practice B.

Timeline of Events

• Day 1: Patient B visits Practice B to register as a new patient. The receptionist searches the Personal Demographics Service (PDS) and selects the first matching record for “Mr. Patient, 12/03/1985” which is Patient A.
• Day 2: Patient B is registered using Patient A’s NHS number.
• Week 1: Patient B receives a prescription for asthma medication, but they don’t have asthma. They contact the practice to query the record.
• Week 2: Practice B notices that Patient B’s record contains immunisation history and GP notes from Birmingham, which she denies ever receiving.

Root Cause

• The confusion occurred because the practice selected the wrong record from the PDS due to identical name and date of birth.
• No additional identifiers (e.g. address, previous GP, NHS number confirmation) were verified before registration.

Consequences

• Clinical Risk: Patient B  was nearly prescribed medication based on Patient A’s history.
• Data Breach: Patient B gained access to Patient A’s confidential medical information.
• Operational Disruption: Both practices had to pause record updates and coordinate with PCSE and the National Back Office (NBO).

Resolution Process

1. Practice B raised a confusion case via the PCSE online form.
2. PCSE responded to the practice and requested they contact their patient to provide previous addresses and practices.
3. Once all the information was received, PCSE flagged the issue to the National Back Office, who confirmed the NHS number was incorrectly assigned.
4. Patient B was allocated a new NHS number, and their record was separated from Patient A’s.
5. Both practices were instructed to update their systems, correct any medical record data, notify the patients, and monitor for further discrepancies.

Lessons Learned

• Always verify multiple identifiers before selecting a record from the PDS.
• Use NHS Smartcards and check address history, previous GP, and postcode.
• Train reception staff on the risks of demographic matching errors.
• Flag similar-name patients in EMIS/SystmOne to prevent future confusion.

Scenario

Two patients were linked to the same NHS number on PDS due to an error when registering one of the patients, causing a confusion. The confusion was resolved by National Back Office (NBO), but 4 hours later, one of the practices registered the patient using the incorrect NHS number, causing the patients to be re-confused.

Patient Profiles

• Patient A: Resident of Leicester, correctly registered with NHS number X.
• Patient B: Resident of Nottingham, correctly registered with NHS number Y.

Timeline of Events

• Initial Resolution: A previous confusion between these two patients was resolved by the National Back Office (NBO), which hid incorrect data and reinstated correct entries.
• 4 Hours Later: A re-confusion occurred when the Leicester GP practice mistakenly re-registered Patient A using Patient B’s NHS number. 

Root Cause

• The GP practice failed to follow through on the resolution process and re-added previously hidden data.
• The incorrect NHS number was used during re-registration, causing the confusion to re-emerge.

Consequences

• Medical Record Misrouting: Patient B’s records were sent to Patient A’s GP, and vice versa.
• Clinical Risk: Both patients were at risk of receiving incorrect treatment.

Lessons Learned

• Before re-registering a patient, please ensure that you have received communication that the confusion has been resolved, and the correct NHS number to use has been confirmed.   

Scenario:

A confusion occurred when two patients were linked to the same NHS number on PDS due to an error when registering one of the patients.

Patient Profiles:

• Patient A: Mr. Patient, born 12 March 1985, Birmingham, registered at Practice A.
• Patient B: Similar demographic details, registered at Practice B.

Issue:

• Both patients’ records were merged under one NHS number.
• Clinical correspondence and prescriptions were misdirected.
• Screening invitations were sent to the wrong individual.

Challenges Faced

• Patient A was difficult to contact:
  • No current phone number on record.
  • Address history inconsistent across systems.
  • Practice had limited previous details (no email, old address).
• Multiple attempts to reach Patient A delayed resolution by several weeks.
• PCSE and NBO required additional demographic details (previous addresses, place of birth) to confirm identity.

Resolution Steps

1. PCSE logged the confusion case to NBO.
2. NBO initiated an investigation and requested:
   • Previous addresses.
   • Place of birth.
   • Any known aliases.
3. Once Patient A eventually responded, the correct NHS number was confirmed.

Impact of Delay

• Clinical Risk: Incorrect medication could have been prescribed.
• Data Breach Risk: Confidential information sent to wrong patient.
• Operational Impact: Resolution extended beyond standard 10-week timeframe due to lack of contact details.

Lessons Learned

• Always collect multiple contact points (phone, email, previous addresses) during registration.