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Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 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.
Garnerin P, Arès M, Huchet A, et al. Qual Saf Health Care. 2008;17:454-8.
This study combined implementation of verification protocols with periodic audits and feedback to increase compliance with patient identification in the prevention of wrong-patient and wrong-site surgery. While the process did improve, the authors advocate for technological solutions to address the limitations of purely manual systems. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery.