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Gloucestershire has three nightmare medical never events

By The Citizen  |  Posted: December 12, 2013

Gloucestershire had three medical never events

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A catalogue of medical nightmares which took place at UK hospitals was released by the NHS today.

The so-called 'never events' list includes 168 horrific cases of medical procedures gone wrong.

Gloucestershire Hospitals NHS Foundation Trust had three never events but due to patient confidentiality it is unable to say which ones happened at county hospitals.

Two of the Gloucestershire cases involved a 'foreign object' being left in patients after medical procedures and one case involved the 'wrong implant or prosthesis' being used on patients.

The report provides a summary of never events which happened between April 1, 2013 and 30 September 30, 2013.

Never events are classified by the NHS as "serious, largely preventable patient safety incidents that should not occur if existing national guidance or safety recommendations had been implemented by healthcare providers."

They include:

37 cases of 'wrong site surgery' including:

• The wrong fallopian tube removed for ectopic pregnancy

• Lumbar puncture performed on the wrong infant

• The wrong tooth removed

• An incision cut into the wrong finger

• The wrong toe amputated

• A cardiac procedure performed on the wrong patient

69 cases involving a 'retained foreign object post-operation'. Objects left in patients included:

• A needle

• Surgical swab

• A screw tab

• A humeral disc (used in a shoulder replacement)

• A surgical glove

21 cases of 'wrong implant/prosthesis' including:

• The wrong lens inserted in ophthalmic surgery

• Incorrect knee prosthesis

• The wrong type of ear implant

Gloucestershire Hospitals NHS Foundation Trust said they could not confirm which incidents took place in Gloucestershire for reasons concerning patient confidentiality.

However in a statement the Trust said: "We work hard and are completely committed to delivering the best possible patient care. On the rare occasions when things don’t go as they should it is vitally important for us to both learn from this and to take action.

"Hospital staff have been in close contact with the patients concerned and continue to offer on-going support during what has been a difficult time for them.

"Full and thorough investigations into the three incidents have now been completed and action plans are in place. Some of the actions already undertaken include extra staff training and the introduction of new clinical processes.

"Patients should take reassurance that events like this are incredibly rare. There are 4.6 million hospital admissions that lead to surgical care every year in England. There are around 250 never events reported, which is an incidence rate of 0.005%.

"In addition the NHS is one of the only health systems in the world that is this open and transparent about patient safety incident reporting, particularly around never events.

"The NHS is clear that we need to openly tackle these issues, not ignore them. To that end it is important that we have a working culture where staff continue to be supported in raising concerns and learning."

Detailed list of the latest NHS medical never events

Read more from Gloucester Citizen

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  • spindles12  |  December 12 2013, 2:46PM

    How the heck do you leave a surgical glove inside someone? Did the surgeon push his hand into the cavity and the suction pull the glove off and, if it did, why didn' anyone notice? If that's the sort of thing that can happen then there's something seriously wrong with the NHS. I've just returned from a hospital clinic where, after half an hour past my appointment time, someone came out and said that my paperwork had been put where it shouldn't have and asked if I had been seen by anyone yet!

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  • supernova1  |  December 12 2013, 1:28PM

    What is the point of having a 'half published ' report. We have a choice about which hospital we use for a procedure, it must surely follow that we need to know which ones make mistakes. Knowing this information would be made public might make the hospitals perform better. If we applied this to education, it would be 'We have three c**p schools in the County, you have to guess which one NOT to send your child to'!!!!!!

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