Open Book: Interventions or procedures performed outside operating theatre settings – wrong procedure/wrong site/wrong person (Oct 2017)

This report alerts providers to key findings and actions following review of preventable events relating to interventional procedures. The aim is to learn from the events to prevent future similar events.

This report is relevant to:

• all staff involved in interventions or procedures occurring outside of operating theatres, including but not limited to:
  • radiology (interventional and procedural)
  • delivery suite
  • interventional cardiology
  • rooms-based procedures in hospitals and primary care
• quality improvement, clinical risk and patient safety managers.