By Ken Thomas, medical negligence specialist with Harding Evans Solicitors and Lawyer of the Year (Welsh Law Awards).

The tragic death of Gwent pensioner Graham Davies at Royal Gwent Hospital made national headlines last week. As was reported in the Argus, the 77 year old died after being given the wrong blood during emergency surgery after a mix up with another patient who had the same name.

Patient misidentification is increasingly seen as a widespread problem in healthcare systems. By this we mean mix ups which lead to a patient receiving treatment or medication intended for somebody else.

A study has recently been published which looked at such errors in one South Wales Trust. During a 12 month period ending April 2002 there were a shocking 233 reported incidents – more than 4 a week. One London NHS Trust has publicly stated that near misses are reported every day of the year. The extent of the problem is perhaps inevitably under estimated – many patients and staff may be unaware such errors have occurred.

Thankfully, the mix ups often have no adverse consequences for the patient. However some patients are not so fortunate. Inappropriate treatment may be given or received and perhaps the wrong operative procedure performed – that can obviously occur if the wrong patient is brought to theatre. Other patients may be given the wrong diagnosis.

As the case of Graham Davies has shown, blood transfusions are a particularly problematic area. Drug administration is another area for concern. Such mix ups are not confined to hospital settings – last year I settled a claim for a Gwent man taken ill after his local high street pharmacy gave him drugs meant for another gentleman. Likewise the problem can occur in dental and GP surgeries. Again, I have experience of entries being made in the records of the wrong patient by mistake.

Some of the most widely publicised mix ups have involved IVF clinics and the use of sperm relating to the wrong couple/father.

There are any number of reasons why patient mix ups can occur. Human error will never be totally eliminated. Ill patients may not be in a position to point out any mistakes. Many people do not have English as their first language. Of course, the NHS itself and its staff are widely felt to be overstretched in many quarters and this cannot help.

If the error does come to light, then if the patient has not actually suffered a claim is not likely to be appropriate. However, even then the patient may still wish to lodge a complaint, if nothing else, to try and reduce the chance of the same thing happening to anyone else.