2013年5月9日 星期四

Hospitals reveal 750 'should never happen' blunders

Hospitals reveal 750 'should never happen' blunders

Never events

Related Stories

More than 750 patients have suffered after preventable mistakes in England's hospitals over the past four years, a BBC investigation has found.
The incidents, such as operating on the wrong body part or leaving instruments inside patients, are categorised by the Department of Health as "never events".
This means they are incidents that are so serious they should never happen.
NHS England admitted the figures were too high and said it had introduced new measures to ensure patient safety.

Find the "never events" in your NHS trust

The department has categorised 25 incidents that should never happen if national safety recommendations are followed by medical staff. The BBC discovered through Freedom of Information requests to NHS trusts that the majority of mistakes fell into four categories.
There were 322 cases of foreign objects left inside patients during operations; 214 cases of surgery on the wrong body part; 73 cases of tubes, which are used for feeding patients or for medication, being inserted into patients' lungs; and 58 cases of wrong implants or prostheses being fitted.

Find out more

  • Listen to the full report on BBC Radio 4's The World at One at 13:00 BST on Thursday 9 May
Frances, whose name has been changed to protect her identity, was admitted to hospital last year for a hysterectomy. After her operation, surgeons realised that a swab was missing and had been left inside her.
They immediately carried out a second operation to remove it, but during this procedure a drain was left in her abdomen. A few weeks later, she was taken back into hospital as she was seriously ill and in severe pain.
A routine gall bladder operation left Donna Bowett suffering constant abdominal pain after surgeons left a seven-inch pair of forceps inside her body
Frances underwent emergency surgery to remove the drain, which had caused a large, pus-filled abscess to develop. She has now been left with a colostomy and faces further surgery.
"My initial reaction was 'no'. They can't do it twice," she said.

Start Quote

It's been a life-changing episode because never in my wildest dreams did I think I would end up with a colostomy”
Frances Hysterectomy patient
"They did an internal inquiry and the consultant who was leading the internal inquiry said on a couple of occasions he couldn't understand how this has happened, because the procedures for this sort of thing were written in stone.
"Thinking about it philosophically, better the colostomy than a coffin. I had one foot in a coffin so it's the better option. I'd rather be here than up the crematorium with a wreath on me."
Ian Cohen, a medical negligence solicitor and head of medical negligence at Goodmans Law, based in Liverpool, said the whole system of reporting "never events" was flawed.
"I think the figures are shocking," he said. "They really are the tip of the iceberg.
"There is an emphasis on the 'never event', but actually there is a bigger picture: missing the fact that we have hundred of thousands of adverse incidents, never mind just 25 particular categories. And the danger is that it takes the focus away from a much wider problem."
He argued that hospitals have no incentive to report "never events" because they may have to reimburse the cost of the procedure to the NHS as well as paying for the patients' long-term care.
Margaret's mother died after a feeding tube was inserted into her lungs
"If that's the case, surely that does not encourage openness if there are already problems with the budget in the NHS," he said.
Horrific as these incidents are, it is important to put them in context. On average each year there are 4.6 million hospital admissions to the NHS in England that require surgery. The NHS says the risk of a "never event" happening to you is one in 20,000.
Dr Mike Durkin, director of patient safety for NHS England, said the 700 "never events" were "too many". He said: "One is too many in any week, in any day, in any hospital."
He added that NHS England had started collating the data to help educate staff on better practice.

Start Quote

You feel angry after because you think someone's killed your mum”
"We need to understand what it is, in some systems and in some hospitals, that that team working hasn't produced an effective outcome and a mistake, and a 'never event' has occurred," Dr Durkin said.
"This is not just the concern of one operating theatre in one hospital. It should be the concern of the leadership of that organisation, of the trust, so that they lead that trust and support both the staff in the operating theatres to work effectively, but also recognise their responsibility for leading safety across the whole of the trust."
The World Health Organisation's patient safety checklist has also been adapted for use in England and Wales.
However, when the patient safety rules are not followed, the results can be catastrophic, as Margaret, whose name has also been changed for reasons of privacy, found.
Guilt Her mother was admitted to hospital after a stroke. But medical staff put a feeding tube into her lungs rather than her stomach. Nutritional fluids went into her lungs, she contracted pneumonia and died.
"You feel guilty because when she [was] talking to us she kept saying she wanted to come out, and we kept saying, 'You can't come out, mum, until you get better," Margaret said.
"You feel angry after, because you think someone's killed your mum. No, they probably didn't do it on purpose but that's how it feels. You feel that somebody's killed her."
Margaret is still awaiting a date for an inquest. She thinks staff failed to follow basic procedure by omitting to give her mother an X-ray to check the tube's location. NHS guidance says that, if in doubt, this should be done as a secondary test.

NHS errors mean 57 patients had ops on wrong body part

In an operating theatre That was the right patient wasn't it?
Fifty-seven patients underwent operations on the wrong part of their body last year due to NHS errors, figures show.
The National Patient Safety Agency says these were some of the 111 so-called "never events" in 2009-2010.
These are very serious, preventable patient safety incidents which the government says should not occur.
The Department of Health has added 14 other kinds of incidents to the official list, taking it to 22.
The list includes medical instruments and swabs left in the body after surgery, the wrong route of administration of chemotherapy, death or injury resulting from the transfusion of the wrong blood type and death by falls from unrestricted windows in places such as mental health hospitals.
Hospitals can have funding withheld if a never event occurs.
Wrong-site surgery refers to an operation on the wrong limb or organ (for example wrong knee, wrong eye, wrong kidney) or on the wrong person.

Start Quote

No one wants these to happen, therefore we will not pay hospitals when these events occur. ”
Professor Sir Bruce Keogh NHS Medical Director
After wrong-site surgery, the second highest number of never events (41) related to misplaced feeding tubes in adults and children.
This puts patients at risk of being fed directly into the respiratory tract.
'Unsafe care' Data on never events from previous years was collected differently and cannot be compared, according to the National Patient Safety Agency (NPSA).
Health minister Simon Burns said that unsafe care must not be tolerated.
"We are committed to extending the system of 'never events'. We will introduce clear disincentives through non-payments, just as there will be clear incentives for quality.
"Across the NHS there must be a culture of patient safety above all else. These measures will help to protect patients and give commissioners the powers to take action if unacceptable mistakes happen."
NHS Medical Director, Professor Sir Bruce Keogh, agreed: "Never events by their very name should never occur in a modern NHS.
"The proposed list includes avoidable incidents with serious adverse consequences for patients. No one wants these to happen, therefore we will not pay hospitals when these events occur.
"This will send a strong signal to leaders of the organisation to learn from their mistakes so they don't happen again," he said.

Plymouth's Derriford Hospital reports five serious mistakes

Related Stories

A hospital has reported five "never events" since November which all relate to surgery or treatment to the wrong part of the body, its trust has said.
The patients, who were treated at Plymouth's Derriford Hospital, have not been "seriously or permanently harmed", Plymouth Hospitals Trust said.
The Department of Health says never events are "unacceptable".
The trust added it took the incidents "extremely seriously" and was taking appropriate action.
Never events are defined by the CQC as serious, largely preventable incidents which should not happen.
The trust said three related to surgery and two to radiological treatments or interventions.
In a statement the trust said: "In each instance, the patient involved is aware of the incident, has been offered an apology and will be involved in the full investigation."
It added that as a result it had revised the theatre safety plan.
'Staff devastated' It said: "In healthcare, an organisation that encourages staff to report incidents and works to create a learning culture is actually working towards better patient safety.


Two-years-ago Derriford was warned it risked prosecution after six never events reported in six months.
Four of those were swabs left in patients after operations.
In February 2011, inspectors from the Care Quality Commission made an unannounced visit to the hospital and found that recognised safety checks were not being carried out in some theatres.
However, subsequent inspections found the required improvements had been made.
"Our staff are devastated when anything goes wrong because they come to work to help people and want to provide the highest standard of care every time."
It added that all never events were investigated and recommendations published.
"We perform 80,000 operations each year, some of them extremely complex and high-risk. We want to reassure anyone out there waiting to come in to be treated that the risk to them of something untoward happening is very, very small indeed," the trust said.
The Department of Health said across the country in 2010/11 there were 166 never events reported to strategic health authorities and in 2011/12 there were 326.
The Care Quality Commission (CQC), said: "We are still awaiting further information on these latest incidents before we decide our response, which could well include a further review and inspection at some time in the near future."

Devon hospitals report serious surgical errors

Surgical procedure - generic The never events reported include surgery being carried out on the wrong part of a patient

Related Stories

Devon's four main hospital trusts each made at least two serious surgical errors this year.
The so-called "never events" included three at Plymouth's Derriford Hospital.
A foreign object was left in a patient, surgery was carried out on the wrong area of a patient's body and a wrong dose of insulin was administered.
The Royal Devon and Exeter, Northern Devon Healthcare and South Devon Healthcare trusts each reported two never events.
'Foreign object' At the Royal Devon and Exeter NHS Foundation Trust, one event involved surgery being carried out on the wrong body part and the other involved a misplaced tube.
The trust said it had closed its investigations into the events.
The Northern Devon Healthcare NHS Trust said no harm had been caused to the patient in each of its two cases.
It said the people concerned had received an apology and full investigations had been carried out.
At Torbay Hospital, a wrong implant or prosthesis was used during a procedure. The second incident related to a "retained foreign object post-operation".
These are the only never events ever reported by the South Devon trust.
The trust said both incidents "were swiftly and safely rectified, with no impact upon the individual patients' long-term health".
'Put in safeguards' Last year, Derriford Hospital was warned by the Care Quality Commission (CQC) that it must improve safety or risk prosecution after six never events within a year, including swabs being left in four patients.
The Plymouth Hospitals NHS Trust, which carries out more than 40,000 operations a year and of which Derriford Hospital is part, said it had investigated the events and had put in safeguards to prevent such things happening in the future.
It added its investigations were always subjected to external scrutiny by organisations such as the Strategic Health Authority and the CQC.
Never events are defined by the CQC as serious, largely preventable incidents which should not happen.
Although they are rare, they are serious enough that each requires an investigation.