Operating on wrong side of patient's body among 'never events' at East and North Herts NHS Trust
PUBLISHED: 08:29 12 July 2019
Operating on the wrong part of a patient's body and pumping fluids from a feeding tube into a patient's lung instead of the stomach are just two of the 'never events' recorded by the East and North Herts NHS Trust during 2018/19.
A never event could cause serious harm or even death and is deemed by the NHS to be a largely preventable incident.
A single never event acts as a red flag that an organisation's systems for implementing existing safety advice or alerts might not be robust.
The trust, which runs Lister Hospital in Stevenage and the New QEII Hospital in Welwyn Garden City, recorded six never events during 2018/19.
In seperate incidents, surgeons operated on the wrong side of a patient's body, a biopsy was taken from the wrong lung, and a patient requiring oxygen was given air as the equipment was connected to an airflow outlet.
A nerve block was also given on the wrong side, a wrong lesion was removed from a patient's arm, and a patient was commenced on fluids via a feeding tube that was inadvertently placed in the lung instead of the stomach.
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This month's board papers for the NHS trust say: "Each of these incidents has been investigated fully to understand how they happened and to apply methods to prevent re-occurrence."
Changes which have been made, or are under way, include placing flaps over airflow outlets to act as a barrier to accidental use, and revision of the lung biopsy consent form.
The trust also reported 71 serious incidents during 2018/19, defined by the NHS as where a person "experiences serious or permanent harm".
The majority were due to care-related incidents and falls - 14 and 10 respectively - with other categories relating to admissions, anaesthetics, diagnosis, treatment, resucitation, medication, infection control, safeguarding and violence.
The board papers say: "Learning from serious incidents remains a priority for 2019/20."
In May, there was one serious incident reported - delayed radiology review in diagnosis of lodged foreign body - and there were also five incidents of E. coli bacteraemia that month.
A spokeswoman for the East and North Herts NHS Trust said: "During the last year the Trust has reported six patient safety incidents which meet the national 'never event' criteria. We have a duty to be open and honest with our patients, and when things go wrong we always give an explanation and an apology.
"We also undertake a full safety investigation to understand how this happened, learn from the event and ensure that training and processes are in place to prevent it happening again."