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Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.

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June 23, 2021

Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

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Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.

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