Doctors Perform Wrong Procedure on Woman's Cervix After Waiting Room Mix-Up

A report has said better measures are needed to prevent patient procedure mix-ups in the U.K. after a woman underwent an invasive procedure intended for another patient with a similar name.

The incident occurred in 2019 when a woman, referred to in the report issued Thursday as "Patient A," turned up to a gynaecological clinic for a fertility treatment assessment. Another woman, Patient B, attended at a similar time for a colposcopy—an examination of the cervix. Both women were checked in and sent to the same waiting area.

A nurse then walked in and called for Patient B using her first and last name twice but received no response. The nurse then called out again, this time just using Patient B's first name. Patient A assumed the call was for her, since she had a similar surname to Patient B's first name and because no one else had responded.

The report states the nurse and patient did go over a document outlining Patient B's details, but the two concluded the procedure was for Patient A regardless. No further formal ID checks were recorded and the procedure went ahead.

Patient A left the clinic and only found out she had received the wrong procedure after Patient B went for her appointment, and staff quickly phoned Patient A to apologize. Patient A returned to the clinic and the fertility appointment then went ahead as planned.

The UK's Healthcare Safety Investigation Branch (HSIB) said the incident was a trigger for a national investigation into existing safety controls and factors that contribute to the risk of patient misidentification.

HSIB said such incidents are "not widely reported" and little data on the scale of the issue exists despite outpatient appointments rising from 54 million to 94 million over the past decade.

It recommended that the U.K.'s National Health Service (NHS) in England should review risks associated with patient identification and identify ways to reduce these risks.

Dr. Sean Weaver, deputy medical director at HSIB, said in a statement: "Any invasive procedure carried out incorrectly has the potential to lead to serious physical and psychological harm and erode trust in the NHS.

"In our case, the patient told us she was so distressed after the incident that she did not want to pursue her fertility treatment.

"The safety recommendation we have made is there to encourage cohesive and effective changes at a national level, to reduce the risk of misidentification, and ensure the right patient receives the right procedure."