The UK National Patient Safety Agency has instructed NHS trusts to tighten up their procedures for labelling patients on entry to hospital, and called on hospitals to put protocols in place to ensure that wristbands are always fitted and that safeguards are in place in case they are lost.

After July 2008, patient wristbands must be white with black text, printed where possible, and show details such as name, date of birth and NHS number (and, in Wales, include the first line of the patient's address, which is a requirement of the Welsh government). Patients with known risks, such as allergies, or patients who do not wish to receive blood products, should be given a red wristband with text in black.

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However, patients with severe allergies should continue to maintain the utmost vigilance in spite of these new instructions.

An inquest held in 2006 heard that a thirty-eight-year-old former care worker and mother, Teresa Innes, had been wearing a bright red allergy wrist band and her allergy to penicillin was recorded, in block capitals, in her medical notes, yet she was still given the drug while in hospital, resulting in an anaphylactic reaction that killed her.

The doctor responsible said that he had not seen an allergy band on Ms Innes' wrist and that none of her notes were available to him on the ward during his round.

The ward sister claimed that she had not seen Ms Innes' notes because, when she had taken charge of the ward, she had been given a verbal handover, without reference to any notes. No one had asked to see the notes during the ward round, she said, and she was not aware of the penicillin allergy until the following morning, when she was informed of this by her managers.

Although admitting that she should have been aware of Ms Innes' allergy, the ward sister said: ‘I think it's physically impossible to know every patient's details.’

First published in September 2007

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