Confusion case study 1

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

An NBO investigation into a potential confusion between 2 patients, identifies 3 patients who are using the same NHS number. 

A PDS user confirms they suspect 3 patients have been using the same NHS number, but although the 3 patients are all registered within the same area, no investigations have been carried out to confirm or resolve the triple confusion. 
  
An NBO investigation confirms the correct details for the patient to whom the NHS number was originally issued and as part of the investigation, also identifies that the wife of this patient has 2 NHS numbers.  

The NBO queries the information provided by the PDS user, as the address quoted for the patient involved in the confusion differs to that of his wife and child, prompting the PDS user to contact the patient. Contact with the patient confirms that the current address on his wife and child's PDS records are incorrect updates.

The investigation confirms the correct data for all patients involved in the confusion, and corrects the information held on PDS for the patient whose NHS number had been used by 2 other patients.

The NBO allocates new NHS numbers for the other 2 patients, creating PDS records showing the correct information for both of them. It also advises the Primary Care Support Service of the action required to correct National Health Application and Infrastructure Services (NHAIS).

The NBO also resolves the duplicate registration identified as a result of investigating the reported confusion.

The effect of a confused NHS number is that the patients involved may either have:

• additional information in their clinical record which does not belong to them
• an incomplete clinical record, on which a clinician may make a clinical judgement or may have made a clinical judgement in the past. 

Confusions are therefore clinically dangerous, and put patient safety at risk.

The PDS user's failure to investigate suspicious data demonstrates bad data quality practice.