Surgeons at Norfolk hospital operated on wrong part of patient’s spine
PUBLISHED: 07:55 01 December 2017 | UPDATED: 16:39 01 December 2017
Archant Norfolk Photographic © 2009
Spinal surgery performed in the wrong area and items left inside patients after a procedure or operation.
Those are just some of the safety breaches deemed so serious they should never happen which have occurred at the region’s busiest hospital this year.
The blunders can be revealed as it was shown with five months left of the financial year, the Norfolk and Norwich University Hospital (NNUH) has matched the number of so-called never events it recorded in the whole of 2016/17, whilst the James Paget University Hospital (JPUH) in Gorleston has already gone above last year’s total.
In 2017/18 so far there have been five never events - named as such because they should never happen - reported at NNUH. One related to surgery where the wrong level of the spine was operated on. In another - which occurred in 2015 but was only reported this year - a guidewire was left inside a patient after surgery. And a further mistake saw a swab left inside a patient who later had it removed.
There were a total of five recorded for the whole of 2016/17. These were removing suspected breast cancer from the wrong place, performing a knee replacement on the incorrect side, removing the wrong side of a thyroid gland, and incorrect skin biopsy and a retained guidewire after inserting a central line.
At the James Paget University Hospital in Gorleston, there were two recorded so far in 2017/18 - one where a swab was retained after a procedure and another where a “foreign object” was left in after surgery. This was compared to one in 2016/17 where aspirin was given intravenously instead of orally.
At the Queen Elizabeth Hospital in King’s Lynn there have been none this year, compared to one last year where an object was left in a patient after surgery.
It comes as the health secretary Jeremy Hunt ordered a review by inspectors into never events in NHS hospitals. Mr Hunt told the Health Service Journal: “Every single one of these events is a tragedy for the patient involved, their family and the NHS. This review will help us understand what more we can do to support the NHS to reduce these events, and how we can learn from mistakes on the occasions where things do go wrong – helping us to make never events a thing of the past and ultimately make the NHS the safest healthcare system in the world.”
A spokesman for the Norfolk and Norwich University Hospital said: “We regret the occurrence of any never event and are absolutely committed to ensuring our patients receive the highest quality care.
“We investigate all incidents in order to identify ways to improve and cases are reviewed by a multi-disciplinary team involving doctors, nurses and other professional staff. We report all our clinical incidents to the NHS National Reporting and Learning Service (NRLS), so that any common themes or issues can be identified and lessons shared.
“All identified learnings from these incidents will be shared appropriately within the Trust as part of our drive for continuous improvement and in order to ensure the best care and experience for our patients.
At the James Paget University Hospital, investigations were launched after each event. Director of nursing Julia Hunt said: “Clearly, we don’t expect to see any never events at our hospital. However, on the rare occasion when one does occur, we take the matter extremely seriously and conduct a thorough investigation to establish if there is any learning that can be taken forward to prevent any future occurrence.”
Regulator the Care Quality Commission (CQC) will carry out the review, a move the Department of Health said would bring “independent rigour” to examine what support trusts need to stop incidents from happening.
NHS data showed the number of never events in 2016/17 across the country reached 442. This included 179 cases of wrong site surgery, 107 retained foreign objects, 59 wrong implants and 40 misplaced nasogastric tubes.
Barts Health Trust had the highest number of never events that year with 11 incidents.
In 2015/16, there were 424 never events including 179 wrong site surgeries, 109 retained foreign objects, 49 wrong implants and 26 misplaced nasogastric tubes. The trust with the highest number of never events was Guy’s and St Thomas’ Foundation Trust with 15 incidents.
The CQC said it would aim to share good practice from trusts who had learned from never events.