Eye operation conducted on wrong patient among hospital trust errors

Alarming blunders, including surgeons conducting an eye operation on the wrong patient and fitting an incorrect implant during a hip replacement, have been recorded at a hospital trust.

Bosses have ordered an independent review of ‘safety culture’ after a number of ‘never events’ in the past year, including two serious errors in the last month, at sites run by Sandwell and West Birmingham Hospitals NHS Trust.

The two most recent ‘never events’ – classed as serious, preventable safety failings – both took place this month.

On November 6, a patient received the wrong-size implant in a hip replacement and, on November 12, eye surgeons carried out a scheduled procedure on the wrong patient.

On June 17 this year a patient was given the wrong-size implant during an eye operation and, on December 15 last year, surgeons operated on the wrong area of a patient’s body.

At a meeting of the hospitals trust board, medical director Dr Roger Stedman said that the hip replacement error was recognised very quickly at the end of surgery, and that the patient went back to theatre under the same anaesthetic to rectify the mistake.

A report into the eye operation blunder on November 12 said: “A call to the patient in the waiting room resulted in the wrong patient following the doctor into the procedure room. A failure to correctly identify the patient prior to commencing procedure resulted in the procedure for another patient being carried out on this patient. Error identified when subsequent patient was called and same patient returned.”

Inpatients are given wristbands to help identify them but the error occurred in an outpatient department where no such tags are used, Dr Stedman said.

He added: “The factors that led to this error occurring is again something we definitely need to learn from. We seem to have moved in medicine generally to providing more procedures in an outpatient setting. The setting isn’t one where the same level of robustness and resilience to checking is available.”

The trust runs Sandwell Hospital in West Bromwich, City Hospital in Birmingham and Rowley Regis Hospital.

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Comments for: "Eye operation conducted on wrong patient among hospital trust errors"

do lallytap

My god this is just BASIC !

My bet is that staffing levels have been cut by that much it's causing errors but it won't be the bosses making the cuts who will get the flack it will be those at roots level.

Unbelievable !!


It is basic. It is good news that none of the patients concerned suffered harm and the two events this month were immediately rectified. I am certain that these events had nothing to do with staffing levels and that any flak should fall on me as Chief Executive, and will not fall on our teams. But what we are doing is working Trust-wide to make sure we learn from what happened and then in January we have asked some senior people from other healthcare organisations to work with us to see if we have done everything that we can. Nobody at SWBH wants a Never Event to befall a patient. 1.5 million people used our service last year, we have lots of indications of high quality (low infection rates and better than expected mortality), but this should not have happened and we are working to make sure it does not reoccur. We are doing that in public (hence this report in the paper) - because the NHS belongs to us all. Tobylewis@nhs.net


It happened to a friend of mine, he had both legs removed by accident, but he managed to sell his slippers so every cloud...

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