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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 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.

Key findings: Wide variability in the fidelity of the RED intervention. Engaged leadership and multidisciplinary implementation teams were keys to success. Common challenges included obtaining timely follow-up appointments, transmitting discharge summaries to outpatient clinicians, and leveraging information technology. Eight out of 10 hospitals reported improvement in 30-day readmission rates after RED implementation. The authors concluded that a supportive hospital culture is essential for successful RED implementation. A flexible implementation strategy can be used to implement RED and reduce readmissions.