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  • HSIB: Wrong site surgery – wrong patient: invasive procedures in outpatient settings (June 2021)

    • UK
    • Investigations
    • Pre-existing
    • Original author
    • No
    • Healthcare Safety Investigation Branch
    • 03/06/21
    • Health and care staff, Patient safety leads


    This Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks involved in the correct identification of patients in outpatient departments. Correct identification is crucial to make sure they receive the right clinical procedure.

    In the last 10 years the number of patients treated in outpatient clinics has nearly doubled. Many minor surgical procedures can now be carried out in an outpatient clinic, whereas in the past they would have been carried out in an inpatient theatre setting.

    The high number of patients treated in an outpatient clinic requires efficient management. Clinical consultation and delivery of the required intervention often needs to be completed within a 15-20-minute appointment. In a single outpatient waiting area there may be patients arriving for different clinical interventions. Staff need to make sure that all patients are seen in the right place, at the right time and (if required) receive the right procedure.

    Outpatients are not provided with any physical means that staff can use to identify them. This is different to inpatients where a wristband is worn following an initial check of the patient’s identity. Checking the identity of a patient in an outpatient department typically relies on staff speaking to patients. There is a risk of patients being missed or misunderstood due to the environment, work demands, language or cultural barriers.


    HSIB reviewed the NHS national reporting systems to understand how often the wrong patient receives the wrong procedure. It launched this national investigation because the evidence found suggests that incorrect identification of patients is a contributory factor to patients receiving the wrong procedure.

    Safety recommendation

    • HSIB recommends that NHS England and NHS Improvement leads a review of risks relating to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise. This should assess the feasibility to enhance or implement layers of systemic controls to manage these risks. It should also consider existing challenges relating to the usability and practice of including the NHS unique identifier in patient identification processes, and consider technological solutions to support its use.

    Safety observations

    • It would be beneficial if scheduling, resources, and organisational performance targets were considered relative to the associated demand for care and interventions, as staff workload may influence the integrity and sustainability of safety checks in an outpatient setting.
    • It would be beneficial if it was easier for trusts to find clear national guidance on what a good patient identification check looks like to assist the quality and consistency of trust guidance.
    • It would be beneficial if the risks associated with patient identification in an outpatient department are considered within staff education and in the procurement and implementation of technical systems.
    • It would be beneficial if there was national guidance on the principles for good design of tools to support the critical task of patient identification. Safety observation O/2021/114: It would be beneficial if trusts trained or employed suitably qualified and competent patient safety specialists to align with the national Patient Safety Syllabus currently under development.
    HSIB: Wrong site surgery – wrong patient: invasive procedures in outpatient settings (June 2021) https://www.hsib.org.uk/documents/318/HSIB_full_report_wrong_site_surgery_wrong_patient.pdf
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