Mock up image of the report investigating the outpatient appointments intended but not booked after inpatients stays

Outpatient appointments intended but not booked after inpatient stays


The national investigation

We 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.

Reference event

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.

People attend hospital for a variety of reasons including diagnostic tests and treatments. Some people may need to stay for one night or more in hospital and are known as ‘inpatients’. Some people may only be required to attend appointments at clinics without an overnight stay. These people are referred to as ‘outpatients’. Commonly, after an inpatient hospital stay, people may be seen at a future date in an outpatient clinic to review their progress or agree next steps for their treatment.

Investigation summary

This investigation:

  • Identified factors which compromise the booking of outpatient follow-up appointments after an inpatient stay.
  • Considered opportunities for building resilience into the booking process for follow-up appointments.