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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. 

TitleIssue dateType
Recognising and instigating prompt treatment for necrotising fasciitis | Signal28 February 2012Signal
Prevention of Harm with Buccal Midazolam | Signal28 February 2012Signal
Risk of harm following gastric bypass | Signal28 February 2012Signal
Diagnosis of death after cessation of cardiopulmonary resuscitation | Signal28 February 2012Signal
Patient safety issues related to gastrostomy | Signal28 February 2012Signal
The adult patient’s passport to safer use of insulin30 March 2011Alert
Risk of harm to patients who are nil by mouth | Signal14 February 2011Signal
Missed diagnosis of fractures in children | Signal14 February 2011Signal
Patient Environment Action Team (PEAT) results 2010: additional data14 October 2010Data report
Delayed diagnosis of cancer: Thematic review26 March 2010Data report
Analysing Significant Event Audits in general practice02 November 2009Guidance
Risk to patient safety of not using the NHS Number as the national identifier...24 June 2009Alert
WHO Surgical Safety Checklist26 January 2009Alert
Quarterly Data Summary Issue 10: Learning from reporting - patient...01 November 2008Data report
Standardising wristbands improves patient safety03 July 2007Alert
Right patient, right blood: advice for safer blood transfusions09 November 2006Alert
Right patient, right blood: core competencies09 November 2006Alert
Safer patient identification22 November 2005Alert
Establishing a standard crash call telephone number in hospitals24 February 2004Alert