Surgeons operated on the wrong side of a patients body during one of four failed hospital procedures that should never have happened, a new report has shown.
Four so-called "never events," that should not happen within the NHS, were reported at Nottingham's Queen's Medical Centre and City Hospital from April 1, 2023 to February 29, this year, according to NHS England. The health body says between April 1, 2023, and February 29, this year, there were 345 serious never events. It added 22 serious incidents did not meet the definition of a never event.
These were serious, largely preventable, patient safety incidents that should not happen if staff follow existing national guidance. Nottingham University Hospital (NUH) NHS Trust, which runs two facilities in the city, initially said it could not share information about what happened as it would count as personal information that would breach the Data Protection Act 2018.
But it later detailed three of the important failings in its board papers over the past year. A so-called "wrong side" never event happened in June last year, according to NUH board documents. According to the NHS, wrong side surgery is classified as an invasive procedure performed on either the wrong patient or a different part of the body than the intended one.
One "never event" recorded at the Queen's Medical Centre involved a patient being operated on the wrong part of their body (NottinghamshireLive/BPM)The failing was reported in July 2023 and was still being reviewed in November that year. The papers also showed a naso gastric tube, which is given to patients in order to provide them with nutrition and hydration, was "misplaced" inside a patient in August of last year, the Nottinghamshire Live reported. Guidance states this type of never event occurs when the wrong placement of a tube is not noticed before a feed, flush or when medication administration starts. NUH board documents explained a review would be undertaken to assess how to prevent this happening to other patients.
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NUH did not state what happened during the third never event. "We actively encourage our staff to report never events, and they are reported to our Trust Board and relevant regulators," a spokesperson for Nottingham University Hospitals Trust told NottinghamshireLive. "If things go wrong, we tell patients and relatives what happened, apologise and explain what actions will be taken to prevent any recurrence in the future. We have clear and robust processes and policies in place to reduce the risk of never events happening and to ensure that we provide the safest possible care to our patients. Never events are rare. If one occurs, we use the national framework to investigate and to learn from what went wrong to inform future practice."
Sherwood Forest Hospitals NHS Foundation Trust, which runs King's Hospital, had one never event in the same time period. Phil Bolton, chief nurse at Sherwood Forest Hospitals, said: “Keeping patients safe is our top priority and we take this kind of incident very seriously as a single event of this nature is one too many. While they should never happen, we actively encourage staff to report them when they do occur so we can learn from what went wrong and reduce the risk of it happening again in the future. We work with the patients and families affected, as well as our staff, to understand what happened, ensure they are all properly supported, and consider how we can further improve the care we provide to the tens of thousands of patients we come into contact with every year.”
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