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

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.

Summary

We thank HSIB for their report and for highlighting the distressing events described in their investigation. We agree that risks exist in relation to the identification of patients in outpatient clinics and that there is potential for mis-identification to occur. We also note that as the reports states, the scale of the risk of misidentification of patients in an outpatient setting is unknown.

HSIB’s recommendation asks for a significant programme of work to be initiated by NHS England and NHS Improvement’s national patient safety team in response to this incident. Our assessment is that this work would require determination of the true scale and impact of the risks identified, examination of multiple rather than single incidents, and examination of relevant risks in situ, including through ethnographic and other types of observational studies. Once complete, identification of meaningful and proportionate actions to address those risks would require design and iteration prior to implementation.

In all, this would be a significant and resource-intensive programme of work that is currently unfunded and so would require resources to be removed from other priorities. At this time, there is insufficient evidence that the scale of this risk would justify such a reallocation of the available resources.

We also note the reference to assessing the usability and practice of including the NHS unique identifier in patient identification processes and consideration of technological solutions to support its use. While we understand the rationale here, we are also aware of the very practical need to be able to identify patients on the basis of information they have to hand and will be able to reference confidently, such as their name, date of birth and address. We are concerned that knowledge of NHS number is not sufficiently widespread to support its routine use by patients in this way.

On that basis, the national patient safety team will not be acting on this recommendation at this time, although we will continue to lead and support a range of wider work that supports correct patient identification across settings.

Full response

HSIB’s recommendation asks for a significant programme of work to be initiated by NHS England and NHS Improvement in response to this incident. Conducting a review of risks relating to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise and assessing the feasibility to enhance or implement layers of systemic controls to manage these risks would require significant resources to be invested in this work and removed from other priorities. We are also concerned that, despite HSIB’s application of clinical and human factors expertise during their national investigation, you were not able to identify any specific recommendations for safety improvement in this area. This suggests to us that the chances of success for any additional work may not be high.

At this time, there is insufficient evidence that the scale and impact of this area of risk and the likelihood of success would justify such a reallocation of resources from areas where those resources can have a greater impact on significant patient safety risks.

We also note the reference to assessing the usability and practice of including the NHS unique identifier in patient identification processes and consideration of technological solutions to support its use. While we understand the rationale here 3 and have supported and promoted the safety benefits of the unique NHS number for many years, we do not believe it is the answer at the point a patient arrives in an outpatient setting. The specific challenge here is to link the patient with their records, and robust methods of doing that have to rely on information all patients have to hand and will be able to reference confidently, such as their name, date of birth and address which in combination provide a unique identifier. Systems that relied on patients carrying or recalling their own NHS number on arrival at an outpatient clinic are likely to increase risk for those patients who will inevitably forget to bring it with them, or imperfectly recall the sequence of numbers. While increasing use of the NHS app driven by the current pandemic may be improving that situation, we are not yet aware that patient use of the NHS number is sufficiently widespread to support its routine use in this way.

On that basis, NHS England and NHS Improvement will not be acting on this recommendation at this time, although we will continue to lead and support a range of wider work that supports correct patient identification across settings, including technological solutions led by NHSX and NHS Digital, and advice and guidance on specific challenges like unidentified casualties.

We further note that this recommendation and the response that we have had to provide potentially reveals a wider system gap. We appreciate that HSIB’s remit is to deliver expert patient safety investigations and to make recommendations to bodies that it feels can act in response to the findings of those investigations. However, in this case, HSIB’s findings and recommendations reveal a need for a function that can dedicate significant resource to more in-depth examination of risks and issues following an initial investigation. There have been similar recent HSIB recommendations that in essence suggest more extensive investigations or explorations are needed to understand the issue. These require significantly more work than any single incident investigation to explore the true scale and impact of the risks identified, and examination of those risks in situ, including through ethnographic and other types of observational studies. In the absence of HSIB or ourselves being able to undertake that work then there may be a piece missing from the system response.

Having noted this, we will discuss this issue further with colleagues in DHSC.

Responses received on 27 August 2021.