Between May 2015 and April 2016, a total of eleven ‘never events’ were reported by various hospitals within the Merseyside area, according to NHS England.
The potentially life-changing mistakes are labelled ‘never events’ as they should never happen and each time one occurs, it must be reported to authorities. The ‘never event’ is then investigated in order to ensure that similar blunders do not reoccur.
Merseyside Hospitals – ‘Never events’
Five cases of ‘wrong site surgery’
A ‘wrong site surgery’ is when an operation is either performed on the wrong part of the body or, in some extreme cases, the wrong patient. Since May 2015, cases of ‘wrong site surgery’ were reported by the following hospitals: Royal Liverpool and Broadgreen hospital trust in August 2015 and January 2016; Wirral Community NHS Trust in July 2015 and Alder Hey in June 2015 and January 2016.
Two cases of drugs administrated by the ‘wrong route’
Such cases include intravenous drugs taken orally and vice versa. Such occurrences can lead to dangerous side effects, depending on the type of drug being taken. Arrowe Park and Clatterbridge hospitals reported a case in October 2015, as did Southport and Ormskirk Hospitals in November 2015.
A feeding tube wrongly inserted into a patient’s lungs
Gastric tubes can be wrongly inserted into the respiratory tract of a patient, instead of the gastrointestinal tract i.e. fed into the lungs instead of the stomach. This sort of ‘never even’ can be fatal if not detected and corrected immediately. Such an incident was reported by Royal Liverpool and Broadgreen Hospital trust in December last year.
A foreign object left inside a patient after surgery
Items left inside patients after surgery include surgical instruments such as scalpels, as well as needles, wires, sponges and towels. Such mistakes most likely require further surgery in order to remove the object. In December 2015, the Royal Liverpool and Broadgreen trust reported an incident in which an object was left inside a patient following surgery.
A patient given the wrong implant or prosthesis
When the wrong implant or prosthesis is inserted into a patient, there is most likely corrective surgery required – leading to major disruption for the individual. A patient at the Liverpool Heart and Chest Hospital was given the wrong implant or prosthesis in October 2015.
A patient given overdose of insulin
Such mistakes are often managed safely; however in extreme instances too much insulin can lead to seizures, unconsciousness and even fatalities. In September 2015, a patient at Liverpool Women’s Hospital was given an overdose of insulin.
‘We take ‘never events’ extremely seriously’
Addressing the incidents reported, the medical director of the Royal Liverpool and Broadgreen University Hospitals NHS Trust, Dr Peter Williams, said:
“We take ‘never events’ extremely seriously, we are open about them, we learn from them and we take action to make further improvements in the care we provide to patients.”
Meanwhile, a spokesman for Alder Hey the following:
“We take any incident extremely seriously and conduct a thorough investigation to identify the cause of any incident, recommend key learnings and reduce the likelihood of similar incidents happening in the future.”
Director of nursing and midwifery at Liverpool Women’s Hospital, Dianne Brown, added:
“The trust does not experience many ‘never events’.
“However, when we do, the public can be assured that we investigate them thoroughly and try to learn as much from them as we can so as to ensure they do not happen again.”
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Source: Liverpool Echo