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.