A patient received the wrong sized prosthetic implant during surgery at a specialist orthopaedic hospital, in Gobowen, near Oswestry. At the Robert Jones and Agnes Hunt (RJAH) hospital in May, Shropshire NHS bosses found out that a small implant was inserted into a patient rather than a medium-sized one. This is the third never event to take place at RJAH, in the past two years.
According to the NHS, never events are serious incidents that could have been avoided provided that healthcare providers implemented existing national guidance or safety recommendations. In July this year, the hospital was also placed under investigation after it emerged that two patients had been injected in the wrong side of their bodies.
From the minutes from a directors’ meeting, the patients were said to be “fine” and that “immediate remedial actions” were taken.
The Local Democracy Reporting Service said that this never event was reported to the Shropshire, Telford and Wrekin Clinical Commissioning Group (CCG) governing body in September and will be discussed in a subsequent meeting.
Although RJAH has not clearly stated the type of surgery carried out or the function of the implant, in its latest report it said that “no further immediate actions were required” after reviewing the surgery.
In the UK, performing the wrong surgery or performing surgery on the wrong patient are termed “never events” because they are not expected to occur in the first place. Between August and October 2015, 190 never events were recorded in the UK which included retained objects in 46 patients and wrong site surgery in 79 patients.
The most recent report from NHS England shows that 226 never events occurred between 1st April and 30th November 2020. The breakdown of this report shows that there were;
- 87 surgeries performed on the wrong body site
- 52 retained objects
- 18 misplaced naso- and oro-gastric tubes
The NHS defines “never events” as serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.
Lists of Never Events (As Updated February 2021) Include;
- Wrong site surgery
- Wrong implant/prosthesis
- Retained foreign object post procedure
- Mis-selection of a strong potassium solution
- Administration of medication by the wrong route
- Overdose of insulin due to abbreviations or incorrect device
- Misplaced naso- or oro-gastric tubes
- Unintentional connection of a patient requiring oxygen to an air flow meter
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