Documentation and patient safety

Correct and up-to-date documentation is essential to help prevent patient safety incidents. Documentation includes patient records and patient identification.

Incidents relating to documentation include:

• Patients being incorrectly identified, or nor identified at all, are at risk of being mismatched to their care. They may receive the wrong treatment or may not be treated at all.

• Patients who require regular blood transfusions are at particular risk of having the wrong blood type administered (ABO incompatibility). This means they need more stringent identification and checks. 

The National Reporting and Learning Service has produced resources to help healthcare organisations avoid patient safety incidents by producing correct and up-to-date patient documentation.

Resources relating to patient documentation are listed below.