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Risk to patient safety of not using the NHS Number as the national identifier for all patients

Risk to patient safety of not using the NHS Number as the national identifier for all patients - thumbnail image
Reference number
0759
Central Alert System (CAS) reference
NPSA/2009/SPN002
Issue date24 June 2009
Action date (if applicable) (date field)18 September 2009
DH Gateway reference
12115
TypeAlert

This Safer Practice Notice advises all NHS organisations to use the NHS Number as the national identifier for all patients.

 

Reports to the National Reporting and Learning Service (NRLS) about incidents arising from reliance on local hospital numbering systems demonstrate that there is real danger to patients of serious harm or death.

 

Between June 2006 and August 2008, the NRLS received over 1,300 reports of incidents resulting from confusion and errors about patients’ identifying numbers. Many involved duplication in local numbering systems, for example, two patients having the same number, or one patient having more than one number. No deaths or cases of serious harm were reported, but healthcare staff believed that it was causing significant risk to patient safety.

 

All NHS organisations should:

  1. Use the NHS Number as the national patient identifier; OR the NHS Number as the national patient identifier in conjunction with a local hospital numbering system.
  2. Use the NHS Number in/on all correspondence, notes, patient wristbands and patient care.
  3.  Put processes in place to ensure that patients can know their own NHS Number and are encouraged to make a note of it.
  4. Primary care organisations should inform patients about their NHS Number in writing whenever they register as a new patient.
CLARIFICATION: 10 September 2009

Since the Safer Practice Notice was reissued, the NPSA have been contacted by some healthcare providers (including dentists, optometrists, community pharmacists, ambulance services and community nurses) stating that they are currently unable to comply with the recommendations in the Safer Practice Notice though many of them wish to do so. This is because some healthcare organisations cannot access or search for NHS Numbers.

 

Guidance on current action

The NPSA, NHS CFH and IHC accept that the healthcare organisations concerned cannot, at present, comply with all the SPN recommendations. Healthcare organisations can, however, comply with some of the recommendations and should prepare for the time when they can access and search for NHS Numbers. This should include: 

  1. Where the NHS Number is available, using it in correspondence with the patient.

  2. Where the healthcare organisation has received correspondence without an NHS Number from a healthcare organisation that can access or search for the NHS Number, requesting the NHS Number from the sending organisation.

  3. Assisting patients to know more about their NHS Number, which can include displaying the NHS CFH leaflet about the NHS Number which is available from NHS Connecting for Health.

  4. Full clarification statement below

Risk to patient safety of not using the NHS Number
Risk to patient safety of not using the NHS Number - 514 KB 0759 - Risk to patient safety of not using the NHS Number - 2009.06.24 -V1
NHS number - clarification statement Sep 09
NHS number - clarification statement Sep 09 - 53 KB 0759 | NHS Number clarifications | 2009-09-10 | v1