Patient safety alert on risk of associating ECG records with wrong patients

December 2018

Nursing

Country of origin: UK

An NHS England patient safety alert has been issued to all NHS services in England that use ECG machines to diagnose cardiac problems. The alert highlights the risk of printing the wrong patient’s ECG records in error, which could lead to misdiagnosis and incorrect treatment.

The alert has been issued following a recently reported patient safety incident where the ‘copy’ button had been pressed on the ECG machine in error instead of the ‘auto/start’ button. This resulted in a copy of the previous patients’ ECG results being re-printed; staff did not immediately realise the error and labelled the ECG record incorrectly with the new patient’s identifiers. As a result, the patient underwent an unnecessary procedure and had a further complication.

The NHS England Patient Safety Domain identified 17 previous incidents reported from across the country since January 2008, describing occasions where the ECG of a previous patient was re-printed; none of these additional incidents resulted in harm to the patient.

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