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Confusion case study 2

Confusions are clinically dangerous, and put patient safety at risk. Find out about how a confusion could be created, and what can be done to resolve it.

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This case study highlights the need for Personal Demographics Service (PDS) users to always:   

  • validate patient data
  • investigate suspicious data
  • use given names for new born babies, if known 
  • report PDS data quality incidents to the National Back Office (NBO) via the service desk

Case study

NHS numbers are issued by maternity to newborn twins. The correct demographics are added to each of the birth notifications, and inserted on to the PDS.

The PDS records for each twin are updated 5 weeks later, with incorrect name and date of birth information. The incorrect updates were identified as automatic updates to the PDS records, as a result of the civil registration of births file scheduled to run and update PDS on a weekly basis.

The hospital then synchronises its local Patient Administration System (PAS) with PDS, causing locally held data to be updated with incorrect demographic data held on Spine.

At 6 weeks old, twin 1 attends A&E. The incorrect data now held on the hospital system causes twin 1 to be booked into hospital under twin 2's NHS number. This results in the clinical information for twin 2 being presented as that of twin 1. 

The doctor has provided care to the twins previously and identifies the error prior to any treatment being provided. The identification of this error is assisted by details held in the blood screening system at the hospital, which is not connected to the Spine, and therefore still holds correct data for the twins. 

The hospital finds no guidance available about how to report the incident, or about steps needed to correct the errors the updates have caused on its local system. The hospital believes one of the twins has also been in contact and treated at another hospital, but doesn't know what details are held by the other hospital. It confirms requests for specialised tests have been sent to a third hospital, but it doesn't know what details are held by that hospital. 

PDS transaction history shows that a further incorrect update to one of the twins' records has been applied by a fourth hospital. It's not possible to establish why this hospital applied the update, particularly as the update was applied when both twins were in another hospital's A&E department. The incident is escalated to NBO to investigate and resolve. 

The confusion created a clinically dangerous situation, as the clinician may have made a clinical judgement about twin 1 based on twin 2's clinical record.  

The automatic update to the PDS records based on the civil registration of births matching criteria created a data quality incident, which put a baby's safety at risk.

Last edited: 6 September 2022 5:32 pm