One of the main areas where the NHS needs to improve patient safety is the reduction and, where possible, elimination of errors in the matching of patients with their care. There are no accurate figures on the frequency or cost of such mismatching errors but we know from the evidence that is available that they account for a significant proportion of errors made in healthcare. Patient safety incidents can occur, for example, when a patient is given the wrong treatment as a result of a failure to match samples, specimens, or x rays; when a patient is given the wrong treatment as a result of a failure in communication or checking; or when one patient is given treatment intended for another as a result of a failure to identify him or her correctly.

In 2000, an expert group chaired by Sir Liam Donaldson, the Chief Medical Officer, noted that adverse events occur in around 10% of NHS admissions or at a rate of about 850 000 patient safety incidents a year.¹ Around half of these incidents are preventable. The UK is not alone in this because research has shown similar …