Serious “Never Events” Still Occurring in NHS
NHS England has recorded almost 1,200 ‘unacceptable serious events’ that have occurred in hospitals over the past four years. Such errors, classified as “never events”, include objects being left inside bodies, falls through windows that were not properly secured, operations on the wrong patient and wrong limb and a kidney being removed instead of an ovary.
The log of “never events” from the past four years, kept by NHS England, shows a relatively steady trend. Between April 2012 and March 2013, a total of 290 events were recorded, in 2013/2014 338 were recorded, in 2014/2015 there were 306. From April 2015 to December that same year, the last month of recorded figures, 254 incidents were recorded. However, this figure will be adjusted accordingly if and when there are further reports of “never events”.
In an interview with the Guardian last week, health secretary Jeremy Hunt stressed the need for healthcare staff to learn from their own mistakes, as well as those of others. Mr Hunt went on to say:
“I want to normalise openness and transparency.”
Over 1000 Errors Recorded
Errors that have been recorded include the removal of a fallopian tube instead of the patient’s appendix and the removal of an entire testicle instead of the cyst on it. In total for the year ending March 2015, there were 102 cases whereby a foreign object was left inside a body after a wound was stitched, 8 cases were the wrong eye was operated on and 27 cases in which the wrong tooth or teeth were removed. Within that same year there were four cases of misidentification of patients and two cases of a transferred prisoner escaping.
Over the past four years, in total, there have been over 420 patients who have suffered after having a foreign object left inside them after surgery. Objects include the likes of drill guides, swabs, scalpel blades, needles and gauzes.
There have been potentially fatal cases whereby feeding tubes have been inserted into a patient’s lungs instead of their stomach and more than 400 people have been left suffering due to “wrong site surgery”.
NHS England has also recorded cases within the last four years whereby the dosage of drugs given to a patient was too high. Other patients have suffered after being given the wrong type of joint replacement or implant and there have even been cases of patients receiving the wrong type of blood during a transfusion.
Hospital with Highest Number of Events
In terms of the number events that occur at each hospital trust, these are logged separately without any details of what the incident involves. For the year ending March 2015, with 9 events recorded in total, Colchester Hospital University NHS Foundation Trust had the highest number of “never events”.
A spokesperson for NHS England has said:
“One never event is too many and we mustn’t underestimate the effect on the patients concerned,
“However there are 4.6m hospital admissions that lead to surgical care each year and, despite stringent measures put in place, on rare occasions, these incidents do occur.
“To better understand the reasons why, in 2013 we commissioned a taskforce to investigate, leading to a new set of national standards being published last year specifically to support doctors, nurses and hospitals to prevent these mistakes. Any organisation that reports a serious incident is also expected to conduct its own investigation so it can learn and take action to prevent similar incidents from being repeated.”
Chief executive of the Patients Association, Katherine Murphy, said:
“It is a disgrace that such supposed ‘never’ incidents are still so prevalent. With all the systems and procedures that are in place within the NHS, how are such basic, avoidable mistakes still happening? There is clearly a lack of learning in the NHS.
“These patients have been very badly let down by utter carelessness. It is especially unforgivable to operate on the wrong organ, and many such mistakes can never be rectified.”
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Source: The Guardian