Investigation at N&N after medical tube is inserted into wrong part of patient

The Norfolk and Norwich University Hospital.

The Norfolk and Norwich University Hospital. - Credit: PA

Hospital bosses have launched an investigation after doctors mistakenly placed a tube into the wrong area on a patient during an operation.

Hospital bosses have launched an investigation after doctors mistakenly placed a tube into the wrong area on a patient during an operation.

The blunder occured at Norfolk and Norwich University Hospital (NNUH) and managers say lessons will be learned.

Doctors meant to place a naso-gastric tube through the patient's oesophagus (gullet) but accidentally put it in the patient's trachea (windpipe), where it potentially can cause a blockage.

The tube was not removed straight away because the hospital's normal checking process didn't immediately identify that the tube had entered the trachea.


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The patient, who was not harmed by the mistake, was unconscious at the time.

Peter Chapman, the trust's medical director, said: 'We are investigating whether this was a matter of human error or if there was some other cause, and any way that we can improve and strengthen our systems.'

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He said the patient was told what had happened after the operation.

The incident has been categorised as a 'never event' - errors so serious they should never happen.

In response the hospital has launched a 'Root Cause Analysis', which is carried out by doctors, nurses, and other staff.

Their findings will be shared with the NHS National Reporting and Learning Service, so that any common themes or issues can be identified and lessons shared.

The report will also be sent to Norfolk's clinical commissioning groups, which are responsible for healthcare in the area.

Naso-gastric tubes are used routinely in hospitals. They are mainly for feeding or giving medicines to patients who are unconscious or unable to swallow.

The openings of the oesophagus and trachea are next to each other at the back of the throat.

An NNUH spokesman added: 'We will also communicate any lessons with our staff, as part of our endeavours to continually improve and to provide the best care that we can to our patients.'

The incident is the second 'never event' at the hospital this financial year.

No 'never events' have been recorded at James Paget University Hospitals NHS Foundation Trust and Queen Elizabeth Hospital King's Lynn NHS Foundation Trust so far in 2015/16.

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Email nicholas.carding@archant.co.uk

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