HSIB: Outpatient appointments intended but not booked after inpatient stays (29 April 2021)

Summary

The Healthcare Safety Investigation Branch (HSIB) have identified a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient stay.

If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment.

The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made.

Content

HSIB recommendations

• HSIB recommends that NHS England and NHS Improvement develops standards and an operating framework that describes the assurance required for all outpatient appointment booking processes, including after an inpatient stay. The assurance should include feedback mechanisms which provide safeguards that intended outpatient appointments are booked. Ideally, solutions will use technology and automation to create resilience and efficiency so that there is less reliance on staff vigilance.
• HSIB recommends that NHSX’s What Good Looks Like programme includes a requirement for organisations to be responsive to HSIB reports and recommendations within the ‘Safe Practice’ section of its guidance.