A young woman sits with her arms folded anxiously in a waiting area.

Wrong site surgery – wrong patient: invasive procedures in outpatient settings

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

We started an investigation looking 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.

‘Outpatients’ are people who attend hospital for consultations, diagnostic tests and procedures, but who do not need to stay overnight. Those who need to stay in hospital for one night or more are known as ‘inpatients’.

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.

Reference event

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

Investigation summary

This investigation will:

  • Draw on the field of human factors to understand how the outpatient context influences the reliability of patient identification.
  • Seek to identify the risks associated with the identification of patients specifically attending for invasive procedures in outpatients, and potential opportunities to manage or minimise them.