HSIB reviewed the NHS national reporting systems to understand how often the wrong patient receives the wrong procedure. They 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:

Drew on the field of human factors to understand how the outpatient context influences the reliability of patient identification.
Sought 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.

Read the full report