Studies have suggested that medical errors may be the third-leading cause of death in the United States, right behind heart disease and cancer.
For the past eight years in an effort to curb the number of preventable mistakes that happen in Indiana, hospitals, ambulatory surgery centers, abortion clinics and birthing centers have been required to report 28 serious adverse events to the Indiana State Department of Health.
In 2013, 111 medical errors occurred at 293 facilities, according to a report recently released by state health officials. That's more medical errors than have occurred in any year since the state started requiring facilities to report these events.
As in seven of the eight years that the report has been produced, serious bed sores lead this year's list of preventable medical errors, with 45 such incidents...
Bedsores
Once again, so-called pressure ulcers, acquired after a person is admitted, topped the list. An average of 32 stage three or four sores have occurred each year.
In 2013, 45 incidents of serious bedsores were reported, more than in any other year since the report was first published.
The elderly and others who are confined to bed because of illness are particularly prone to bedsores. So facilities are supposed to keep a watchful eye on their patients to ensure that small problems don't get out of hand and potentially lead to lethal infections.
Foreign objects
In some cases, surgeons are supposed to take things out of one's body. In others, they're supposed to put things in (think stents for clogged arteries). But on 27 occasions, surgeons in Indiana left a "foreign object" in a patient after surgery.
The Indiana State Department of Health does not require facilities to go into detail on their reports, so it's impossible to know exactly what those foreign objects were.
NoThing Left Behind, a national project to reduce the number of "retained surgical items" notes that common objects left behind include soft goods/sponges, needles, instruments and "miscellaneous small items."
Although one incident occurred in the previous year and was just reported now, the total is more than a 50 percent increase from the number of such events reported for 2012.
Wrong site surgeries
You've heard stories about doctors removing the wrong leg, operating on the opposite arm. Some patients have even taken to marking the right body part before they go under the knife.
Still, mistakes happen. On 13 occasions in the past year, an Indiana hospital performed surgery on the wrong body part, and in five cases, the fault was that of an ambulatory surgery center, for a total of 18 such incidents.
It should be noted that even if a surgeon stops before actually doing the full surgery, it counts under this category. So that could mean anything from a doctor numbing the wrong leg and then realizing his or her mistake before proceeding to actually operating on that leg.
In two other cases, the wrong surgical procedure was done.
Serious falls
It seems so mundane, but fall prevention is a critical piece of what hospitals must do to keep patients as healthy as possible. On 12 occasions, all in hospitals, a patient's fall resulted in either death or a serious disability.
Each year, an estimated 700,000 to 1 million patients fall in hospitals. Of these, as many as half result in an injury.
To encourage hospitals to work harder to prevent falls, the federal government in 2008 started refusing to pay for extra care necessitated by a fall while a patient was hospitalized.
This article is courtesy of indystar.com.
Regularly updated blog featuring news, articles and information relating to clinical/medical negligence.
Showing posts with label Never Events. Show all posts
Showing posts with label Never Events. Show all posts
Wednesday, 15 October 2014
Monday, 15 September 2014
Awareness during surgery can cause long-term harm, says report
At least 150 and possible several thousand patients a year are conscious while they are undergoing surgery in the operating theatre, according to a report which warns that some people suffer long-term psychological damage as a result.
In the vast majority of cases, patients have been given muscle-relaxing drugs that temporarily paralyse them, preventing them from warning theatre staff that they are awake. It happens most often during caesarean sections under general anaesthetic and during heart surgery.
A three-year investigation carried out by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland found that usually the experience of awareness was short-lived, at the beginning or end of the operation.
Half of those who were aware of what was happening to them were distressed by the experience, and 41% said they suffered long-term psychological harm. The sensations they experienced included tugging, stitching, pain, paralysis and choking.
Patients described feelings of dissociation, panic, extreme fear and suffocation. Some said they feared they had been entombed, buried alive or were dead.
Prof Jaideep Pandit, consultant anaesthetist at the John Radcliffe hospital in Oxford and one of the authors of the report, said the Royal College and Association had "recognised the problem officially for the first time".
He said: "For a long time it has been a discussion on the periphery. This is real. We need to understand it and tackle it."
Not all experiences were traumatising, he said. Some patients spoke of feeling removed from what was happening. The drugs did not cause unconsciousness but made them feel detached. Sometimes they felt this was acceptable, and Pandit said there was an unanswered question as to whether all patients would want oblivion during surgery or whether some might prefer pain-free awareness.
It was vital, however, he said, that patients are told before they have surgery that there is a possibility, however remote, of having some consciousness of what is going on.
Estimates of how often this happens vary, says the report. When patients are asked after surgery whether they had any awareness, one in 600 say yes. But only one in 19,000 will come forward to talk about it voluntarily after the surgery. That would put the numbers at between 150 and 4,500 a year.
The team looked at three million episodes where a general anaesthetic was given in a hospital and reviewed in detail 300 cases of awareness reported by patients.
In 97% of cases, patients received muscle-relaxing drugs as well as the general anaesthetic. This makes it harder for an anaesthetist to be sure the patient is unconscious.
Around 10% of cases were caused by drug errors. In some, the muscle relaxant had been given without the general anaesthetic, which meant the patient was fully conscious but paralysed throughout their operation.
Where that happened, says the report, there were organisational as well as individual errors. "These included ill-considered policies for drug management, similar-looking ampoules, poorly organised operating lists, high workload, distraction and hurriedness," says the report.
"These patients were severely distressed and severely harmed in the long term," said Pandit. The report recommends a checklist before surgery, which would require the anaesthetist to line up the drugs they intend to administer and point to each one in turn. Pandit said mistakes "seem to occur in a highly pressured environment"
This article is courtesy of The Guardian.
In the vast majority of cases, patients have been given muscle-relaxing drugs that temporarily paralyse them, preventing them from warning theatre staff that they are awake. It happens most often during caesarean sections under general anaesthetic and during heart surgery.
A three-year investigation carried out by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland found that usually the experience of awareness was short-lived, at the beginning or end of the operation.
Half of those who were aware of what was happening to them were distressed by the experience, and 41% said they suffered long-term psychological harm. The sensations they experienced included tugging, stitching, pain, paralysis and choking.
Patients described feelings of dissociation, panic, extreme fear and suffocation. Some said they feared they had been entombed, buried alive or were dead.
Prof Jaideep Pandit, consultant anaesthetist at the John Radcliffe hospital in Oxford and one of the authors of the report, said the Royal College and Association had "recognised the problem officially for the first time".
He said: "For a long time it has been a discussion on the periphery. This is real. We need to understand it and tackle it."
Not all experiences were traumatising, he said. Some patients spoke of feeling removed from what was happening. The drugs did not cause unconsciousness but made them feel detached. Sometimes they felt this was acceptable, and Pandit said there was an unanswered question as to whether all patients would want oblivion during surgery or whether some might prefer pain-free awareness.
It was vital, however, he said, that patients are told before they have surgery that there is a possibility, however remote, of having some consciousness of what is going on.
Estimates of how often this happens vary, says the report. When patients are asked after surgery whether they had any awareness, one in 600 say yes. But only one in 19,000 will come forward to talk about it voluntarily after the surgery. That would put the numbers at between 150 and 4,500 a year.
The team looked at three million episodes where a general anaesthetic was given in a hospital and reviewed in detail 300 cases of awareness reported by patients.
In 97% of cases, patients received muscle-relaxing drugs as well as the general anaesthetic. This makes it harder for an anaesthetist to be sure the patient is unconscious.
Around 10% of cases were caused by drug errors. In some, the muscle relaxant had been given without the general anaesthetic, which meant the patient was fully conscious but paralysed throughout their operation.
Where that happened, says the report, there were organisational as well as individual errors. "These included ill-considered policies for drug management, similar-looking ampoules, poorly organised operating lists, high workload, distraction and hurriedness," says the report.
"These patients were severely distressed and severely harmed in the long term," said Pandit. The report recommends a checklist before surgery, which would require the anaesthetist to line up the drugs they intend to administer and point to each one in turn. Pandit said mistakes "seem to occur in a highly pressured environment"
This article is courtesy of The Guardian.
Monday, 8 September 2014
Surgeon rendered patient infertile by giving him a vasectomy by mistake during minor operation
A surgeon has rendered a patient infertile by giving him a vasectomy when he went into hospital for a minor operation.
The patient was the victim of what hospital chiefs have called a 'never event' - a medical mistake that should never happen.
The man, who had the original procedure at Broadgreen Hospital in Liverpool earlier this year, has been told that an operation to reverse the vasectomy was unsuccessful. He could now be entitled to more than £100,000 in compensation.
It is understood that the surgeon who performed the surgery has since been fired, according a report.
The urology department at Broadgreen Hospital, part of the Royal Liverpool and Broadgreen University Hospitals NHS Trust, has admitted the error was just one of five botched operations - and two 'never events' - in the last 12 months.
Another mistake involved a medical swab being left inside a patient during an operation.
The Royal Liverpool Hospital 'apologised unreservedly' to the man when details of the mistake, which they termed 'wrong site surgery', emerged earlier this year.
The vasectomy - and the failed reversal - means that the patient will not be able to conceive naturally.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said the vasectomy patient could be eligible for more than £100,000 in compensation, but it would depend on how old he is and whether or not he has been left infertile.
Mr Cohen said: 'This is a truly shocking and worrying case. From what we know there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'If a 25-year-old who wants a family is told he won’t be able to father children, it will be devastating.'
Hospital bosses say the blunders have been reported to NHS chiefs and that investigations are under way to establish how they happened.
Dr Peter Williams, medical director at Royal Liverpool and Broadgreen University Hospitals NHS Trust said: 'Our urology department is the biggest in Cheshire and Merseyside, caring for over 4,000 patients a year.
'The vast majority of feedback from these patients is overwhelmingly positive.
'We have excellent, highly regarded clinical teams who treat the most difficult urological cases, many of which are referred to us by other hospitals for our expertise and leading edge surgical techniques.
'In the last 12 months, three serious incidents and two never events occurred in our urology department and these were reported to the appropriate bodies.
'We are still in the process of investigating some of these incidents, including looking at how to improve the processes and systems in place and are taking appropriate action.
'We cannot comment on the outcomes of these investigations at this stage.
'Patient safety is always our priority and we use the lessons learnt from any incident to continually improve our standard of care.'
This article is courtesy of the Daily Mail.
The patient was the victim of what hospital chiefs have called a 'never event' - a medical mistake that should never happen.
The man, who had the original procedure at Broadgreen Hospital in Liverpool earlier this year, has been told that an operation to reverse the vasectomy was unsuccessful. He could now be entitled to more than £100,000 in compensation.
It is understood that the surgeon who performed the surgery has since been fired, according a report.
The urology department at Broadgreen Hospital, part of the Royal Liverpool and Broadgreen University Hospitals NHS Trust, has admitted the error was just one of five botched operations - and two 'never events' - in the last 12 months.
Another mistake involved a medical swab being left inside a patient during an operation.
The Royal Liverpool Hospital 'apologised unreservedly' to the man when details of the mistake, which they termed 'wrong site surgery', emerged earlier this year.
The vasectomy - and the failed reversal - means that the patient will not be able to conceive naturally.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said the vasectomy patient could be eligible for more than £100,000 in compensation, but it would depend on how old he is and whether or not he has been left infertile.
Mr Cohen said: 'This is a truly shocking and worrying case. From what we know there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'If a 25-year-old who wants a family is told he won’t be able to father children, it will be devastating.'
Hospital bosses say the blunders have been reported to NHS chiefs and that investigations are under way to establish how they happened.
Dr Peter Williams, medical director at Royal Liverpool and Broadgreen University Hospitals NHS Trust said: 'Our urology department is the biggest in Cheshire and Merseyside, caring for over 4,000 patients a year.
'The vast majority of feedback from these patients is overwhelmingly positive.
'We have excellent, highly regarded clinical teams who treat the most difficult urological cases, many of which are referred to us by other hospitals for our expertise and leading edge surgical techniques.
'In the last 12 months, three serious incidents and two never events occurred in our urology department and these were reported to the appropriate bodies.
'We are still in the process of investigating some of these incidents, including looking at how to improve the processes and systems in place and are taking appropriate action.
'We cannot comment on the outcomes of these investigations at this stage.
'Patient safety is always our priority and we use the lessons learnt from any incident to continually improve our standard of care.'
This article is courtesy of the Daily Mail.
Wednesday, 20 August 2014
Leeds hospital blunders revealed in report
Doctor wrongly removed a woman’s kidney after mistaking it for an ectopic pregnancy, a new report on serious incidents at Leeds hospitals shows.
Two patients also received adrenaline overdoses, there was an outbreak of MRSA among new mums and staff failed to respond when a patient deteriorated, according to the document.
It details 16 serious incidents recorded by Leeds Teaching Hospitals NHS Trust in May and June, with 11 of these pressure ulcers.
The report, by chief medical officer Dr Yvette Oade, says there has been an increase since 2013 in the number of serious incidents.
She said: “Whilst this reflects our reporting and learning culture, this is also attributable to a decision that we took to report all category 3 pressure ulcers as serious incidents from January 2014.”
In another incident, a woman was taken to theatre for removal of a suspected ectopic pregnancy, where a foetus implants outside the womb and cannot survive.
Before the procedure, the surgeon did not review a previous scan which showed one of her kidneys was in her pelvis.
“During the procedure the surgeon identified a structure thought to be the ectopic pregnancy, and removed this,” the report said.
However that was then identified as a pelvic kidney. The woman was not found to have an ectopic pregnancy.
After the error, staff were reminded of the guidelines for treating the condition and there was a meeting about the incident.
In two cases, patients were given too much adrenaline – one who was given ten times the prescribed dose then lost vision in one eye. The sight loss was later found to have occurred at the time of the overdose.
In another incident, a patient on the Critical Care Unit had been prescribed adrenaline at a rate of 5mls per hour following surgery, but it was mistakenly given at 50mls an hour. They needed further surgery but later recovered.
A further incident happened when a patient with diabetes began to deteriorate and was supposed to be monitored every two hours, but this did not happen. The next morning they could not be woken and were treated, but there were delays.
The patient continued to deteriorate due to their underlying illness and died the next morning. A post mortem confirming the cause of death is awaited.
There was also an outbreak of MRSA infection of the skin of mothers who had been discharged from the post-natal ward at LGI. Apologies were given to those affected.
In all cases, the incidents were investigated and moves made to prevent them recurring.
This article is courtesy of the Yorkshire Evening Post.
Two patients also received adrenaline overdoses, there was an outbreak of MRSA among new mums and staff failed to respond when a patient deteriorated, according to the document.
It details 16 serious incidents recorded by Leeds Teaching Hospitals NHS Trust in May and June, with 11 of these pressure ulcers.
The report, by chief medical officer Dr Yvette Oade, says there has been an increase since 2013 in the number of serious incidents.
She said: “Whilst this reflects our reporting and learning culture, this is also attributable to a decision that we took to report all category 3 pressure ulcers as serious incidents from January 2014.”
In another incident, a woman was taken to theatre for removal of a suspected ectopic pregnancy, where a foetus implants outside the womb and cannot survive.
Before the procedure, the surgeon did not review a previous scan which showed one of her kidneys was in her pelvis.
“During the procedure the surgeon identified a structure thought to be the ectopic pregnancy, and removed this,” the report said.
However that was then identified as a pelvic kidney. The woman was not found to have an ectopic pregnancy.
After the error, staff were reminded of the guidelines for treating the condition and there was a meeting about the incident.
In two cases, patients were given too much adrenaline – one who was given ten times the prescribed dose then lost vision in one eye. The sight loss was later found to have occurred at the time of the overdose.
In another incident, a patient on the Critical Care Unit had been prescribed adrenaline at a rate of 5mls per hour following surgery, but it was mistakenly given at 50mls an hour. They needed further surgery but later recovered.
A further incident happened when a patient with diabetes began to deteriorate and was supposed to be monitored every two hours, but this did not happen. The next morning they could not be woken and were treated, but there were delays.
The patient continued to deteriorate due to their underlying illness and died the next morning. A post mortem confirming the cause of death is awaited.
There was also an outbreak of MRSA infection of the skin of mothers who had been discharged from the post-natal ward at LGI. Apologies were given to those affected.
In all cases, the incidents were investigated and moves made to prevent them recurring.
This article is courtesy of the Yorkshire Evening Post.
Monday, 18 August 2014
Wrong site surgeries remain top hospital mistake
The surgeon(s), anesthesiologist, scrub nurse, circulating nurse, the surgical techs, and residents stand in the surgical suite. Also in the room is a patient prepared for surgery. The team is going to amputate his lower left leg because he has complications from diabetes. Before performing the procedure, the surgical team forms a huddle to review the surgery that is before them and to ground themselves. When the surgery is completed, instead of the patient’s lower left leg being amputated the team amputated the patient’s lower right leg.
Though statistics vary widely, The Joint Commission, an organization which governs the accreditation of health care organizations, suggests that wrong site surgeries occur 40-60 times in the U.S. each week. Wrong site surgeries are considered to be sentinel events, unexpected occurrences involving psychological injury or serious physical injury or death . The Joint Commission requires sentinel events to be reported and investigated so that the root cause of the mistake can be determined. According to the governing body, breakdown in communication is the primary culprit for wrong site surgeries. After analysis, it has been found that 85 percent of wrong site surgeries occur because of inadequate planning. 72 percent have been attributed to defects in surgeons’ “time outs.” Surgeon “time outs” are breaks taken before a procedure begins, to ensure that all of the details regarding the forthcoming surgery are correct.
Most wrong site surgeries occur during orthopedic, urologic, and neuro-surgical procedures. Odds of wrong site surgeries increase when the surgery involves multiple procedures. For example, when a trauma patient has multiple fractures, surgical teams may make mistakes on which sites require operation.
“Around the country, surgical teams have adopted the practice of forming these huddles or time outs before surgeries,” said Sara Perkins, a Manager of Employee Health at a local hospital in Vancouver, Wash. Perkins, however, is not a surgical nurse. Speaking about the time out procedure her hospital utilizes, Perkins said, “The objective is to confirm that the patient before the team is going to receive the surgery that is needed. The time out leader explains how the surgery will go and questions are asked and answered before the first incision is made.”
Despite time outs, wrong site surgeries continue to occur throughout the nation’s operating rooms. Sometimes the time outs simply do not take place, as may be the case in a severely life-threatening trauma situation where minutes count in saving the patient’s life. Other times, distractions arise and make it difficult for the whole team to come together. The phone might ring. Previous procedures may go longer than expected, making some team members later to the surgical suite than would be optimal. Staff may be rushed, moving between procedures, so that not all team members are fully engaged in the time out.
In small hospitals that do not have multiple surgical teams, an emergent trauma can require team members to toggle between patients. Surgical suites are generally kept small and cool to facilitate a sterile environment. Exchanging team members after the patient has been prepped and draped has the potential of breaking the sterile environment and is discouraged; nevertheless, it sometimes happens. The new staff may not be fully briefed, unlike the team that was present during the pre-surgical timeout.
The Joint Commission requires healthcare to report them and investigate the root causes as to why each of these events have occurred. Medicaid’s decision to deny funding for procedures and care resulting from wrong site surgeries is fairly new. This effectively puts the financial burden of care for these patients back onto the shoulders of hospitals. Despite this further incentive to only perform surgeries on patients that are needed, wrong site surgeries are still one of the biggest mistakes that hospitals make.
A brochure published by The Joint Commission is listed in the “Sources” section at the end of this article. The brochure suggests that to help reduce risk of medical mistakes and wrong site surgeries, patients should consult with their healthcare provider before surgery, to make sure that they do not take any medication that will create ill effects during or after surgery. Also, the patient is advised to make sure that markings placed on their body before surgery accurately reflects the body part on which the surgery is to take place. The video below demonstrates the World Health Organization’s (WHO) protocol for conducting a pre-surgical time out. Team members identify themselves, their roles, and the procedure that is going to take place. This procedure has reduced the incidence of wrong site surgeries, though they continue to occur.
This article is courtesy of the Liberty Voice.
Though statistics vary widely, The Joint Commission, an organization which governs the accreditation of health care organizations, suggests that wrong site surgeries occur 40-60 times in the U.S. each week. Wrong site surgeries are considered to be sentinel events, unexpected occurrences involving psychological injury or serious physical injury or death . The Joint Commission requires sentinel events to be reported and investigated so that the root cause of the mistake can be determined. According to the governing body, breakdown in communication is the primary culprit for wrong site surgeries. After analysis, it has been found that 85 percent of wrong site surgeries occur because of inadequate planning. 72 percent have been attributed to defects in surgeons’ “time outs.” Surgeon “time outs” are breaks taken before a procedure begins, to ensure that all of the details regarding the forthcoming surgery are correct.
Most wrong site surgeries occur during orthopedic, urologic, and neuro-surgical procedures. Odds of wrong site surgeries increase when the surgery involves multiple procedures. For example, when a trauma patient has multiple fractures, surgical teams may make mistakes on which sites require operation.
“Around the country, surgical teams have adopted the practice of forming these huddles or time outs before surgeries,” said Sara Perkins, a Manager of Employee Health at a local hospital in Vancouver, Wash. Perkins, however, is not a surgical nurse. Speaking about the time out procedure her hospital utilizes, Perkins said, “The objective is to confirm that the patient before the team is going to receive the surgery that is needed. The time out leader explains how the surgery will go and questions are asked and answered before the first incision is made.”
Despite time outs, wrong site surgeries continue to occur throughout the nation’s operating rooms. Sometimes the time outs simply do not take place, as may be the case in a severely life-threatening trauma situation where minutes count in saving the patient’s life. Other times, distractions arise and make it difficult for the whole team to come together. The phone might ring. Previous procedures may go longer than expected, making some team members later to the surgical suite than would be optimal. Staff may be rushed, moving between procedures, so that not all team members are fully engaged in the time out.
In small hospitals that do not have multiple surgical teams, an emergent trauma can require team members to toggle between patients. Surgical suites are generally kept small and cool to facilitate a sterile environment. Exchanging team members after the patient has been prepped and draped has the potential of breaking the sterile environment and is discouraged; nevertheless, it sometimes happens. The new staff may not be fully briefed, unlike the team that was present during the pre-surgical timeout.
The Joint Commission requires healthcare to report them and investigate the root causes as to why each of these events have occurred. Medicaid’s decision to deny funding for procedures and care resulting from wrong site surgeries is fairly new. This effectively puts the financial burden of care for these patients back onto the shoulders of hospitals. Despite this further incentive to only perform surgeries on patients that are needed, wrong site surgeries are still one of the biggest mistakes that hospitals make.
A brochure published by The Joint Commission is listed in the “Sources” section at the end of this article. The brochure suggests that to help reduce risk of medical mistakes and wrong site surgeries, patients should consult with their healthcare provider before surgery, to make sure that they do not take any medication that will create ill effects during or after surgery. Also, the patient is advised to make sure that markings placed on their body before surgery accurately reflects the body part on which the surgery is to take place. The video below demonstrates the World Health Organization’s (WHO) protocol for conducting a pre-surgical time out. Team members identify themselves, their roles, and the procedure that is going to take place. This procedure has reduced the incidence of wrong site surgeries, though they continue to occur.
This article is courtesy of the Liberty Voice.
Wednesday, 6 August 2014
Fears after NHS surgery mistakes
At least 35 patients have had the wrong part of their body operated on in the past five years, new figures reveal.
Errors include one patient having a needle thrust into the wrong side of their chest during an emergency procedure and several patients having the wrong part of their head operated on.
Patients' groups have hit out at the string of mistakes, saying it was both a tragedy and frightening such mistakes could happen.
Patients are visited by consultant surgeons and anaesthetists before operations and it is standard practice for medics to "draw" on the operation site before the patient goes into theatre.
The details of botched surgeries follow the revelation last month that the Scottish NHS spent more than £186 million on compensation in the past five years.
Four out of Scotland's 14 health boards admitted to operating on the wrong body parts. NHS Greater Glasgow and Clyde admitted there had been 12 occasions in which staff had mistakenly operated on the wrong part of the body. Three involved operations on the head.
A document, released through the Freedom of Information Act, stated the patient's head had been "shaved, prepped, incision made and with the skin open a small amount of dissection was carried out on right side" when it should have been on the left.
NHS Lanarkshire said there had been two occasions when their staff had carried out procedures on the wrong part of the body. Both involved patients being treated for "squints" and they were given "injections to the wrong muscle" in their eye.
NHS Tayside revealed it had 20 incidents in which staff had incorrectly carried out operations or procedures on the wrong part of their body.
NHS Lothian admitted to "five or fewer" errors but refused to give details, claiming patients could be identified. Fife said it did not hold the details. The other boards said there had been no mistakes.
Jean Turner, executive director of Scotland Patients Association said: "The tragedy is that these are not just statistics, but people this has happened to."
A Scottish Government spokeswoman said: "While any surgical error is regrettable, it is important to put these figures in context as they reflect a tiny number of the 1.2 million procedures carried out safely each year.
"We have witnessed a 23 per cent reduction in surgical mortality since 2008, have implemented the World Health Organisation surgical checklist and are committed to further improvements."
This article is courtesy of the Herald Scotland.
Errors include one patient having a needle thrust into the wrong side of their chest during an emergency procedure and several patients having the wrong part of their head operated on.
Patients' groups have hit out at the string of mistakes, saying it was both a tragedy and frightening such mistakes could happen.
Patients are visited by consultant surgeons and anaesthetists before operations and it is standard practice for medics to "draw" on the operation site before the patient goes into theatre.
The details of botched surgeries follow the revelation last month that the Scottish NHS spent more than £186 million on compensation in the past five years.
Four out of Scotland's 14 health boards admitted to operating on the wrong body parts. NHS Greater Glasgow and Clyde admitted there had been 12 occasions in which staff had mistakenly operated on the wrong part of the body. Three involved operations on the head.
A document, released through the Freedom of Information Act, stated the patient's head had been "shaved, prepped, incision made and with the skin open a small amount of dissection was carried out on right side" when it should have been on the left.
NHS Lanarkshire said there had been two occasions when their staff had carried out procedures on the wrong part of the body. Both involved patients being treated for "squints" and they were given "injections to the wrong muscle" in their eye.
NHS Tayside revealed it had 20 incidents in which staff had incorrectly carried out operations or procedures on the wrong part of their body.
NHS Lothian admitted to "five or fewer" errors but refused to give details, claiming patients could be identified. Fife said it did not hold the details. The other boards said there had been no mistakes.
Jean Turner, executive director of Scotland Patients Association said: "The tragedy is that these are not just statistics, but people this has happened to."
A Scottish Government spokeswoman said: "While any surgical error is regrettable, it is important to put these figures in context as they reflect a tiny number of the 1.2 million procedures carried out safely each year.
"We have witnessed a 23 per cent reduction in surgical mortality since 2008, have implemented the World Health Organisation surgical checklist and are committed to further improvements."
This article is courtesy of the Herald Scotland.
Monday, 19 May 2014
Man given vasectomy by MISTAKE after going into hospital for minor op could get £100,000 compensation
A man who went into hospital for a minor operation was given a vasectomy instead, it emerged yesterday.
The surgeon’s ‘catastrophic’ blunder meant the unnamed patient, thought to be of an age at which he hoped to father children, was left sterile.
Doctors, who were meant to be performing a straightforward urological procedure, apologised unreservedly and operated again to reverse the vasectomy.
However, he faces an anxious wait to find out whether he is now fertile again.
In one case in two, a man who has a vasectomy reversed is unable to impregnate his partner naturally and the success rate for fertility treatment is even lower, at about one in four.
Clinical negligence lawyers say the patient could be entitled to a six-figure compensation payout from the hospital.
The mistake is classed by the NHS as a ‘never’ event – one which should never happen if all the proper surgical procedures are followed.
It happened at Royal Liverpool Hospital in February, and the surgeon has been barred from operating while an investigation is concluded.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said: ‘This is a truly shocking and worrying case.
‘From what we know, there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'In a worst case scenario – sterility in a younger man with no children – the trust might be liable for a figure in excess of £100,000 in compensation.’
The hospital trust’s medical director, Dr Peter Williams, confirmed the blunder, adding: ‘We have apologised.
'We greatly regret the distress this has caused him. We are investigating this fully to understand why it occurred and how we can ensure it does not happen again.’
The hospital has refused to give the patient’s age citing medical confidentiality.
However, the fact that a reversal was attempted indicates that he had hoped either to start a family or to have more children.
Trust chief executive Aidan Kehoe told a board meeting it appeared that a World Health Organisation surgical safety checklist had not been followed.
Last year, Health Secretary Jeremy Hunt revealed there had been 326 ‘never’ events in 2011/12.
Among them 161 patients with foreign objects such as swabs left in their bodies, 70 suffering wrong-site surgery – where the wrong part of the body is operated upon – and 41 given incorrect implants.
Another 148 such incidents were recorded by NHS England between April and September last year.
This article is courtesy from The Daily Mail.
The surgeon’s ‘catastrophic’ blunder meant the unnamed patient, thought to be of an age at which he hoped to father children, was left sterile.
Doctors, who were meant to be performing a straightforward urological procedure, apologised unreservedly and operated again to reverse the vasectomy.
However, he faces an anxious wait to find out whether he is now fertile again.
In one case in two, a man who has a vasectomy reversed is unable to impregnate his partner naturally and the success rate for fertility treatment is even lower, at about one in four.
Clinical negligence lawyers say the patient could be entitled to a six-figure compensation payout from the hospital.
The mistake is classed by the NHS as a ‘never’ event – one which should never happen if all the proper surgical procedures are followed.
It happened at Royal Liverpool Hospital in February, and the surgeon has been barred from operating while an investigation is concluded.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said: ‘This is a truly shocking and worrying case.
‘From what we know, there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'In a worst case scenario – sterility in a younger man with no children – the trust might be liable for a figure in excess of £100,000 in compensation.’
The hospital trust’s medical director, Dr Peter Williams, confirmed the blunder, adding: ‘We have apologised.
'We greatly regret the distress this has caused him. We are investigating this fully to understand why it occurred and how we can ensure it does not happen again.’
The hospital has refused to give the patient’s age citing medical confidentiality.
However, the fact that a reversal was attempted indicates that he had hoped either to start a family or to have more children.
Trust chief executive Aidan Kehoe told a board meeting it appeared that a World Health Organisation surgical safety checklist had not been followed.
Last year, Health Secretary Jeremy Hunt revealed there had been 326 ‘never’ events in 2011/12.
Among them 161 patients with foreign objects such as swabs left in their bodies, 70 suffering wrong-site surgery – where the wrong part of the body is operated upon – and 41 given incorrect implants.
Another 148 such incidents were recorded by NHS England between April and September last year.
This article is courtesy from The Daily Mail.
Monday, 5 May 2014
Woman sues hospital after surgeons left a four inch plastic tube inside her
A woman is suing a hospital where surgeons left a four-inch plastic tube inside her, resulting in her losing half a lung when it was removed.
Julie Jones, 51, underwent surgery to have her spleen removed in October 2009 and thought she had made a full recovery.
But she claims doctors at St James’ University Hospital, in Leeds, had left a tube inside her lung which threatened to kill her at any moment if it pierced her liver.
The problem was only spotted when Ms Jones, who moved from Leeds to Devon in 2011,
began to feel seriously unwell and went to hospital for a scan and chest X-ray.
Staff at the Royal Devon and Exeter Hospital immediately detected the tube and advised a non-invasive operation to try and remove it.
But after six failed attempts they decided to operate and take out half of her lung, leaving the mother-of-four disabled.
Ms Jones said: 'When the doctor told me that I would have to have part of my lung removed I asked him what exactly the "foreign body" was.
'The doctor just told me I’d been horribly let down on my last operation and showed me the X-ray of my chest.
'When I saw the tube in my lung I was immediately sick, I couldn’t even eat anything for three days because I was so repulsed.
Ms Jones said: 'When the doctor told me that I would have to have part of my lung removed I asked him what exactly the "foreign body" was.
'The doctor just told me I’d been horribly let down on my last operation and showed me the X-ray of my chest.
'When I saw the tube in my lung I was immediately sick, I couldn’t even eat anything for three days because I was so repulsed.
'How on earth could a team of ten surgeons have missed a four-inch plastic tube with shiny metal clips - it’s terrifying and disgusting.'
She added: 'The surgeons told me that the tube was only one centimetre away from my liver.
'At any minute it could have slipped down and pierced it, killing me.'
Since the operation last November, Ms Jones, a former cleaning supervisor, says she has been left breathless, lethargic and unable to walk more than a few paces.
She said: 'I used to be really active; I used to love walking and I worked for a living.
'Now I can’t even take more than a few steps until I’m knackered.
'I have basically been left disabled for the rest of my life because those surgeons in Leeds left a plastic tube inside me.
'I don’t know if those surgeons were half asleep, drunk or what. But there were ten of them involved in the operation - ten of them - and nobody noticed it. It’s terrifying.'
She added: 'I think people need to know that this sort of thing does happen. How many people might already be dead?'
Ms Jones is now suing The Leeds Teaching Hospitals NHS Trust for medical negligence.
She said: 'I’m never going to get much better than I am now, I’m never going to have normal life again.
'Through their negligence, those doctors have ruined my life - I won’t ever be the same again.
'Just a simple thing like walking to the shops is impossible for me and it’s all the fault of those surgeons - how could they let this happen?'
Leeds Teaching Hospitals NHS Trust has confirmed Ms Jones was a patient at St James’ University Hospital and that they are looking into a legal claim dating back to 2011.
A spokesman said: 'We are unable to comment on this case as a legal claim is ongoing.'
A spokesperson for the Royal Devon and Exeter Hospital NHS Foundation Trust, said: 'I can confirm
this patient had an operation at the Royal Devon and Exeter Hospital where a foreign body was removed from her chest.'
This article is courtesy from The Daily Mail.
Julie Jones, 51, underwent surgery to have her spleen removed in October 2009 and thought she had made a full recovery.
But she claims doctors at St James’ University Hospital, in Leeds, had left a tube inside her lung which threatened to kill her at any moment if it pierced her liver.
The problem was only spotted when Ms Jones, who moved from Leeds to Devon in 2011,
began to feel seriously unwell and went to hospital for a scan and chest X-ray.
Staff at the Royal Devon and Exeter Hospital immediately detected the tube and advised a non-invasive operation to try and remove it.
But after six failed attempts they decided to operate and take out half of her lung, leaving the mother-of-four disabled.
Ms Jones said: 'When the doctor told me that I would have to have part of my lung removed I asked him what exactly the "foreign body" was.
'The doctor just told me I’d been horribly let down on my last operation and showed me the X-ray of my chest.
'When I saw the tube in my lung I was immediately sick, I couldn’t even eat anything for three days because I was so repulsed.
Ms Jones said: 'When the doctor told me that I would have to have part of my lung removed I asked him what exactly the "foreign body" was.
'The doctor just told me I’d been horribly let down on my last operation and showed me the X-ray of my chest.
'When I saw the tube in my lung I was immediately sick, I couldn’t even eat anything for three days because I was so repulsed.
'How on earth could a team of ten surgeons have missed a four-inch plastic tube with shiny metal clips - it’s terrifying and disgusting.'
She added: 'The surgeons told me that the tube was only one centimetre away from my liver.
'At any minute it could have slipped down and pierced it, killing me.'
Since the operation last November, Ms Jones, a former cleaning supervisor, says she has been left breathless, lethargic and unable to walk more than a few paces.
She said: 'I used to be really active; I used to love walking and I worked for a living.
'Now I can’t even take more than a few steps until I’m knackered.
'I have basically been left disabled for the rest of my life because those surgeons in Leeds left a plastic tube inside me.
'I don’t know if those surgeons were half asleep, drunk or what. But there were ten of them involved in the operation - ten of them - and nobody noticed it. It’s terrifying.'
She added: 'I think people need to know that this sort of thing does happen. How many people might already be dead?'
Ms Jones is now suing The Leeds Teaching Hospitals NHS Trust for medical negligence.
She said: 'I’m never going to get much better than I am now, I’m never going to have normal life again.
'Through their negligence, those doctors have ruined my life - I won’t ever be the same again.
'Just a simple thing like walking to the shops is impossible for me and it’s all the fault of those surgeons - how could they let this happen?'
Leeds Teaching Hospitals NHS Trust has confirmed Ms Jones was a patient at St James’ University Hospital and that they are looking into a legal claim dating back to 2011.
A spokesman said: 'We are unable to comment on this case as a legal claim is ongoing.'
A spokesperson for the Royal Devon and Exeter Hospital NHS Foundation Trust, said: 'I can confirm
this patient had an operation at the Royal Devon and Exeter Hospital where a foreign body was removed from her chest.'
This article is courtesy from The Daily Mail.
Monday, 17 February 2014
Parents get compensation after death of four-year-old Matthew Kenway
A hospital trust has paid out a five-figure compensation sum in the wake of a four-year-old's death.
Matthew Kenway died at the Southampton General Hospital after going in there for a routine kidney operation.
Now it has been announced that the family of the youngster, of Bellfield, Fareham, who died in December 2010 on the hospital's High Dependency Unit, are to be paid a five-figure sum in compensation.
An inquest last year heard how Matthew had seemed to be recovering well from his operation but his heart stopped suddenly and he died.
Delivering a narrative verdict, Southampton coroner Keith Wiseman called for “lessons to be learned” after hearing about delays in medical staff spotting that Matthew's heart was failing.
He said: “There was clearly a delay in recognising that there had been cardiac arrest.
“Obviously the passage of any such time could have affected the likelihood of resuscitation being effective.”
Mr Wiseman highlighted an NHS report urging better checks for breathing, circulation and consciousness.
He added: “There was also to be training and reminders to nursing staff on the appropriate escalation process in an emergency situation arising - that is to say, the calling of the cardiac arrest emergency team before physically calling for help to someone nearby, however close.”
Southampton Coroner's Court was told how after surgery Matthew, who had a lifelong muscular condition called congenital fibre-type disproportion, was looked after on the paediatric high-dependency unit but in the early hours the oxygen monitor probe appeared not to be recording anything.
A nurse initially thought the machine might be faulty, but it turned out that Matthew's heart had stopped.
University Hospital Southampton NHS Foundation Trust said following Matthew's death it had now introduced heart monitoring for all infants and children who have had surgery.It emerged Matthew had not been hooked up to a heart monitor and that treatment may have been delayed because an unqualified nurse ran to bring a doctor, rather than raising a cardiac arrest alarm.
The inquest heard Matthew had a congenital condition that made his muscles weaker than usual so he relied on a home ventilator and had a tracheostomy to breathe.
His parents Anthony Kenway and Katie Oxley, represented by clinical negligence specialists from law firm Blake Lapthorn, took legal action against University Hospital Southampton NHS Foundation Trust over the circumstances of Matthew's death.
The Trust has now reached a settlement in which it has agreed to pay an undisclosed five-figure sum to them.
The family's solicitor Patricia Wakeford, of Blake Lapthorn, said: “Evidence heard at the inquest raised grave concerns about the quality of care that Matthew received and the processes that were in place at Southampton General Hospital at the time of Matthew's death.
“Despite their loss, Matthew's family have been determined to remember their son as the lively, happy, much-loved child that he was.
“They hope that important lessons are learned from the events that led to his death and that this will prevent other families suffering a similar tragedy in the future.”
Ms Oxley said: “Nothing can bring Matthew back but we were determined to highlight what went wrong in the hope that lessons could be learned and that no other family would have to suffer what we have been through.
“Knowing that changes have now been made in the high-dependency unit gives us some comfort.
“We will always feel Matthew's loss but we do now feel as if we can start to move on.”
Matthew Kenway died at the Southampton General Hospital after going in there for a routine kidney operation.
Now it has been announced that the family of the youngster, of Bellfield, Fareham, who died in December 2010 on the hospital's High Dependency Unit, are to be paid a five-figure sum in compensation.
An inquest last year heard how Matthew had seemed to be recovering well from his operation but his heart stopped suddenly and he died.
Delivering a narrative verdict, Southampton coroner Keith Wiseman called for “lessons to be learned” after hearing about delays in medical staff spotting that Matthew's heart was failing.
He said: “There was clearly a delay in recognising that there had been cardiac arrest.
“Obviously the passage of any such time could have affected the likelihood of resuscitation being effective.”
Mr Wiseman highlighted an NHS report urging better checks for breathing, circulation and consciousness.
He added: “There was also to be training and reminders to nursing staff on the appropriate escalation process in an emergency situation arising - that is to say, the calling of the cardiac arrest emergency team before physically calling for help to someone nearby, however close.”
Southampton Coroner's Court was told how after surgery Matthew, who had a lifelong muscular condition called congenital fibre-type disproportion, was looked after on the paediatric high-dependency unit but in the early hours the oxygen monitor probe appeared not to be recording anything.
A nurse initially thought the machine might be faulty, but it turned out that Matthew's heart had stopped.
University Hospital Southampton NHS Foundation Trust said following Matthew's death it had now introduced heart monitoring for all infants and children who have had surgery.It emerged Matthew had not been hooked up to a heart monitor and that treatment may have been delayed because an unqualified nurse ran to bring a doctor, rather than raising a cardiac arrest alarm.
The inquest heard Matthew had a congenital condition that made his muscles weaker than usual so he relied on a home ventilator and had a tracheostomy to breathe.
His parents Anthony Kenway and Katie Oxley, represented by clinical negligence specialists from law firm Blake Lapthorn, took legal action against University Hospital Southampton NHS Foundation Trust over the circumstances of Matthew's death.
The Trust has now reached a settlement in which it has agreed to pay an undisclosed five-figure sum to them.
The family's solicitor Patricia Wakeford, of Blake Lapthorn, said: “Evidence heard at the inquest raised grave concerns about the quality of care that Matthew received and the processes that were in place at Southampton General Hospital at the time of Matthew's death.
“Despite their loss, Matthew's family have been determined to remember their son as the lively, happy, much-loved child that he was.
“They hope that important lessons are learned from the events that led to his death and that this will prevent other families suffering a similar tragedy in the future.”
Ms Oxley said: “Nothing can bring Matthew back but we were determined to highlight what went wrong in the hope that lessons could be learned and that no other family would have to suffer what we have been through.
“Knowing that changes have now been made in the high-dependency unit gives us some comfort.
“We will always feel Matthew's loss but we do now feel as if we can start to move on.”
This article is courtesy from The Daily Echo.
Tuesday, 4 February 2014
Basildon Hospital inundated with compensation claims from irate patients as solicitors Leigh Day launches 64 cases
Basildon Hospital is facing hundreds of thousands of pounds in compensation payouts after a legal firm lodged dozens of claims to the trust.
Specialist solicitors Leigh Day has made 64 claims to Basildon Hospital this year from as far back as 2003 as more new cases come to light following the fiasco at Staffordshire Hospitals.
It compares to a total of 57 negligence claims made against the hospital from all solicitors in 2012/13. Leigh Day said the total number of claims against the hospital that year could be even higher.
Claims include patients being left in soiled bedding, delays in treatment and pain relief, and delays in referrals.
In some cases patients allegedly died as a result of the hospital’s actions.
The majority of cases refer to patients aged 60 and over, but one involves a patient under 18.
Most have come to light from 2012, with Leigh Day dealing with three times as many claims during that year than any other.
Emma Jones, solicitor in Leigh Day’s human rights department, said: “We consider these issues to be human rights issues as well as negligent.
“The failure to ensure someone has enough to eat and drink, be given medication and being taken to the bathroom are human rights.”
Leigh Day is dealing with 225 cases from 39 hospitals and 37 hospital trusts across the country.
The number of claims relating to Basildon Hospital account for more than a quarter of all cases being dealt with, and nearly double any other trust. Barking Havering and Redbridge Trust, which has the second highest number of cases against it, faces 34 compensation claims.
Miss Jones added: “It’s difficult to pinpoint exactly why Basildon Hospital has so many more cases against it than other trusts. I think it suggests standards have been noticeably low for a longer period of time.”
Basildon Hospital and the NHS Litigation Authority refused to say the total number of active compensation claims against the hospital.
Relatives of patients who died at the hands of Basildon Hospital have estimated the trust may need to pay out up to £1million in compensation.
While solicitors and Basildon Hospital refused to put a figure on the 64 compensation claims made against the hospital, victims expect the hospital could be out of anything from £60,000 to £1million.
Christine Papalabropoulos, whose daughter Tina died in 2009 of pneumonia, has already been awarded £3,000 compensation from the Health Service Ombudsman – £2,000 from the hospital trust and £1,000 from South Essex Emergency Doctors’ Surgeries. But she is one of 64 who have launched a private compensation claim.
Christine, 57, of Harris Drive, Wickford, said: “It’s not about the money, but about the anger you feel towards the hospital. If you told me there were this many claimants five years ago I would be surprised but nothing surprises me now.
“We are human beings, not a slab of meat, but we are not being treated like human beings.”
Dan Chapple, who founded Cure the NHS after his mother Pam died of a brain haemorrhage, said: “It’s very hard to tell howmuch the hospital will have to pay. It could be anything from £60,000 to £1million. It depends on how many dependents the victim has, how much of their working life is left, and howmuch of a mess the hospital has made.
“I hope Leigh Day doesn’t try to settle out of court for silence, otherwise the problems won’t come to light, will be swept under the carpet, and changes won’t be made.”
Baslidon Hospital had to pay out more than £5million in compensation claims last year.
NHS insurers paid a total of £5,081,234 in 2012/13 for claims against the hospital.
Hospital bosses said the figure is close to the national average.
It paid a total of £2.625million in damages, £1.997million in claimants’ legal costs and £457,894 to cover its own legal fees.
In total, 57 negligence claims were made against Basildon Hospital. This year 64 have been brought against the trust by Leigh Day alone.
Baslidon Hospital has been praised for improving standards of care.
Keogh inspectors, who first visited the hospital in May last year, said the hospital was addressing levels of staffing and concerns about patient care after they inspected the site again in November.
Hospital bosses have agreed to round table discussions with Leigh Day about all their cases in a bid to save legal costs on both sides.
A spokesman for the hospital said: “The trust has received a list from Leigh Day solicitors and we are currently in contact with them regarding a number of these cases.
“We have not received any similar joint actions from other solicitors.
“We would encourage anybodywho is unhappywith their care, or the care provided to a relative, to contact our Patient Advice and Liaison Service so issues can be quickly addressed and we can learn from any mistakes.”
Specialist solicitors Leigh Day has made 64 claims to Basildon Hospital this year from as far back as 2003 as more new cases come to light following the fiasco at Staffordshire Hospitals.
It compares to a total of 57 negligence claims made against the hospital from all solicitors in 2012/13. Leigh Day said the total number of claims against the hospital that year could be even higher.
Claims include patients being left in soiled bedding, delays in treatment and pain relief, and delays in referrals.
In some cases patients allegedly died as a result of the hospital’s actions.
The majority of cases refer to patients aged 60 and over, but one involves a patient under 18.
Most have come to light from 2012, with Leigh Day dealing with three times as many claims during that year than any other.
Emma Jones, solicitor in Leigh Day’s human rights department, said: “We consider these issues to be human rights issues as well as negligent.
“The failure to ensure someone has enough to eat and drink, be given medication and being taken to the bathroom are human rights.”
Leigh Day is dealing with 225 cases from 39 hospitals and 37 hospital trusts across the country.
The number of claims relating to Basildon Hospital account for more than a quarter of all cases being dealt with, and nearly double any other trust. Barking Havering and Redbridge Trust, which has the second highest number of cases against it, faces 34 compensation claims.
Miss Jones added: “It’s difficult to pinpoint exactly why Basildon Hospital has so many more cases against it than other trusts. I think it suggests standards have been noticeably low for a longer period of time.”
Basildon Hospital and the NHS Litigation Authority refused to say the total number of active compensation claims against the hospital.
Relatives of patients who died at the hands of Basildon Hospital have estimated the trust may need to pay out up to £1million in compensation.
While solicitors and Basildon Hospital refused to put a figure on the 64 compensation claims made against the hospital, victims expect the hospital could be out of anything from £60,000 to £1million.
Christine Papalabropoulos, whose daughter Tina died in 2009 of pneumonia, has already been awarded £3,000 compensation from the Health Service Ombudsman – £2,000 from the hospital trust and £1,000 from South Essex Emergency Doctors’ Surgeries. But she is one of 64 who have launched a private compensation claim.
Christine, 57, of Harris Drive, Wickford, said: “It’s not about the money, but about the anger you feel towards the hospital. If you told me there were this many claimants five years ago I would be surprised but nothing surprises me now.
“We are human beings, not a slab of meat, but we are not being treated like human beings.”
Dan Chapple, who founded Cure the NHS after his mother Pam died of a brain haemorrhage, said: “It’s very hard to tell howmuch the hospital will have to pay. It could be anything from £60,000 to £1million. It depends on how many dependents the victim has, how much of their working life is left, and howmuch of a mess the hospital has made.
“I hope Leigh Day doesn’t try to settle out of court for silence, otherwise the problems won’t come to light, will be swept under the carpet, and changes won’t be made.”
Baslidon Hospital had to pay out more than £5million in compensation claims last year.
NHS insurers paid a total of £5,081,234 in 2012/13 for claims against the hospital.
Hospital bosses said the figure is close to the national average.
It paid a total of £2.625million in damages, £1.997million in claimants’ legal costs and £457,894 to cover its own legal fees.
In total, 57 negligence claims were made against Basildon Hospital. This year 64 have been brought against the trust by Leigh Day alone.
Baslidon Hospital has been praised for improving standards of care.
Keogh inspectors, who first visited the hospital in May last year, said the hospital was addressing levels of staffing and concerns about patient care after they inspected the site again in November.
Hospital bosses have agreed to round table discussions with Leigh Day about all their cases in a bid to save legal costs on both sides.
A spokesman for the hospital said: “The trust has received a list from Leigh Day solicitors and we are currently in contact with them regarding a number of these cases.
“We have not received any similar joint actions from other solicitors.
“We would encourage anybodywho is unhappywith their care, or the care provided to a relative, to contact our Patient Advice and Liaison Service so issues can be quickly addressed and we can learn from any mistakes.”
This article is courtesy from the Echo.
Friday, 3 January 2014
Major hospital blunders including 40 patients given surgery on wrong limb, revealed by official statistics
Almost 150 NHS patients have been harmed by incidents that should never happen, according to new figures - including the wrong patient receiving heart surgery, patients given overdoses and a woman who had her fallopian tube removed instead of her appendix.
Official statistics for a six month period show that the major blunders include 37 cases of patients who underwent surgery on the wrong part of the body.
In one case, the wrong patient was given a heart procedure.
One woman had the wrong fallopian tube removed during an ectopic pregnancy, probably rendering her infertile, and another had a fallopian tube removed instead of her appendix.
The wrong patient was given an invasive colonoscopy to check their bowel, while in four cases operations were carried out on the wrong teeth, and in other cases injections were given to the wrong eye.
In 69 cases, surgical instruments, needles swabs, specimen retrieval bags were left inside the body.
The figures disclose for the first time the number of incidents in each NHS hospital, and the types of blunders - some of which have either killed or seriously harmed patients.
In one incident, a drill guide block was left inside the patient’s body.
In another case, the patient died as a result of failure to monitor their oxygen levels, while one woman died from heavy bleeding following a planned Caesarean section.
Another had the wrong type of gas given, resulting in the patient’s death or severe harm, and one patient underwent surgery intended for someone else “due to incorrect results filed in notes”.
In total 21 patients were given the wrong implant or prosthesis. Seven patients were given the wrong dose of chemotherapy, resulting in harm, and five died or suffered severe harm after feeding tubes were inserted incorrectly by NHS staff.
In more than five cases, patients were given overdoses of drugs, with a weekly dose given in a single day.
Until now, only national totals were published.
The 148 incidents in six months suggests figures are “broadly comparable” to previous years, NHS England said, with 325 events in the previous 12 months.
Newcastle upon Tyne Hospitals NHS Foundation trust recorded the highest number of incidents - four in six months, with two patients “retaining foreign objects” one suffering wrong site surgery and one being given the wrong type of prosthesis or implant during surgery.
Nine more trusts recorded three incidents each during the period. They were The Royal Wolverhampton NHS trust, West Middlesex University NHS trust, South Tees Hospitals NHS Foundation trust, Sheffield Teaching Hospitals NHS trust, Leeds Teaching Hospitals NHS trust, Barts Health NHS trust, University Hospitals of Morecambe Bay NHS trust, Gloucestershire Hospitals NHS Foundation trust and Norfolk and Norwich University Hospitals NHS Foundation trust.
Dr Mike Durkin, National Director of Patient Safety at NHS England, said: “Awareness in the NHS of these issues has never been greater and the quality of our surgical procedures has never been better. It follows that the risk of these things happening has never been smaller.
“Every single never event puts patients at risk of harm which is avoidable. People who suffer severe harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS.”
Health Secretary Jeremy Hunt said: “We are determined to see the NHS become a world leader in patient safety - with a safety ethos and level of transparency that matches the airline industry.
“The publication of this data is a real step forward towards making this happen.”
This article is courtesy from The Telegraph.
Official statistics for a six month period show that the major blunders include 37 cases of patients who underwent surgery on the wrong part of the body.
In one case, the wrong patient was given a heart procedure.
One woman had the wrong fallopian tube removed during an ectopic pregnancy, probably rendering her infertile, and another had a fallopian tube removed instead of her appendix.
The wrong patient was given an invasive colonoscopy to check their bowel, while in four cases operations were carried out on the wrong teeth, and in other cases injections were given to the wrong eye.
In 69 cases, surgical instruments, needles swabs, specimen retrieval bags were left inside the body.
The figures disclose for the first time the number of incidents in each NHS hospital, and the types of blunders - some of which have either killed or seriously harmed patients.
In one incident, a drill guide block was left inside the patient’s body.
In another case, the patient died as a result of failure to monitor their oxygen levels, while one woman died from heavy bleeding following a planned Caesarean section.
Another had the wrong type of gas given, resulting in the patient’s death or severe harm, and one patient underwent surgery intended for someone else “due to incorrect results filed in notes”.
In total 21 patients were given the wrong implant or prosthesis. Seven patients were given the wrong dose of chemotherapy, resulting in harm, and five died or suffered severe harm after feeding tubes were inserted incorrectly by NHS staff.
In more than five cases, patients were given overdoses of drugs, with a weekly dose given in a single day.
Until now, only national totals were published.
The 148 incidents in six months suggests figures are “broadly comparable” to previous years, NHS England said, with 325 events in the previous 12 months.
Newcastle upon Tyne Hospitals NHS Foundation trust recorded the highest number of incidents - four in six months, with two patients “retaining foreign objects” one suffering wrong site surgery and one being given the wrong type of prosthesis or implant during surgery.
Nine more trusts recorded three incidents each during the period. They were The Royal Wolverhampton NHS trust, West Middlesex University NHS trust, South Tees Hospitals NHS Foundation trust, Sheffield Teaching Hospitals NHS trust, Leeds Teaching Hospitals NHS trust, Barts Health NHS trust, University Hospitals of Morecambe Bay NHS trust, Gloucestershire Hospitals NHS Foundation trust and Norfolk and Norwich University Hospitals NHS Foundation trust.
Dr Mike Durkin, National Director of Patient Safety at NHS England, said: “Awareness in the NHS of these issues has never been greater and the quality of our surgical procedures has never been better. It follows that the risk of these things happening has never been smaller.
“Every single never event puts patients at risk of harm which is avoidable. People who suffer severe harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS.”
Health Secretary Jeremy Hunt said: “We are determined to see the NHS become a world leader in patient safety - with a safety ethos and level of transparency that matches the airline industry.
“The publication of this data is a real step forward towards making this happen.”
This article is courtesy from The Telegraph.
Saturday, 2 November 2013
Shocking hospital blunders that should NEVER happen
Medics have made dozens of serious mistakes when treating patients across Greater Manchester over the last 18 months.
The preventable errors – known as ‘never events’ because the Department of Health say they should not happen – include an operation on the wrong part of a spine and swabs left in women after childbirth.
Figures obtained by the M.E.N. show 28 patients have been ‘never event’ victims in the region in just 18 months.
Central Manchester Hospitals
There were seven incidents at the Central Manchester Hospitals – which includes St Mary’s, MRI and Manchester Children’s Hospital – in 2012/13 and three so far in the current financial year.
This year’s incidents included one where a wrong mole was removed from a patient’s face.
Swabs were also left inside two patients – one after an operation in the ear, nose and throat department and one in the obstetrics and gynaecology.
Salford
There were two ‘never events’ in Salford last year including one where two drill ‘guides’ were left in a patient and another where the ‘incorrect level’ of a person’s spine was operated on.
There have been a further two events this year.
Wigan
There were also two never events at the Wrightington, Wigan and Leigh Hospitals Trust in 2012/13 – root canal work on the wrong tooth and a swab left inside a patient’s knee.
Another took place this year where a patient received an overdose of a sedative.
The trust said that incident is under investigation and the patient has since recovered.
Royal Bolton Hospital
In two high-profile cases last year, swabs were left inside two women following childbirth at the Royal Bolton Hospital.
A third case of a swab being left inside a woman also happened last year. There has been one separate ‘never event’ at the hospital this year.
Pennine Acute Hospitals Trust
There were two never events at the Pennine Acute Hospitals Trust last year – where a ‘guide wire’ was left inside a patient after a line was fitted and where a swab was left in another patient. The trust runs North Manchester General Hospital, as well as hospitals in Bury, Rochdale and Oldham.
The Christie
An instrument was also left inside a patient at the Christie Hospital last year – the only never event to have taken place at the trust.
Stockport
There were two ‘never events’ at Stepping Hill Hospital in Stockport. A swab was left in a patient following a minor operation and the wrong strength of lens was used in an ophthalmology procedure.
Pennine Care
There was one ‘never event’ last year at Pennine Care, which provides a range of mental health and community services, when packing was left in a patient’s throat after a dental procedure.
Wythenshawe and Tameside
Wythenshawe and Tameside hospitals have had no ‘never events’ in the past 18 months.
Gill Edwards, a partner in the medical negligence department at law firm Pannone, who is also a former nurse, said: “These events should never happen.
“It’s important that hospitals learn from them to prevent them from happening again. It also important that patients are informed about what steps have been taken.”
NHS England is preparing its first set of quarterly lists of never events.
A spokeswoman said: “All never events require a robust investigation to identify why the failing has occurred and to ensure preventative measures are put in place to prevent re-occurrence.”
Have you been a victim of a ‘never event’? Call us on 0161 211 2323.
What the trusts say:
Central Manchester: All never events are pro-actively reported and investigated. Every never event is analysed and we are working hard to ensure similar events do not happen in the future. This work includes liaison with other hospitals to ensure learning across the NHS.
Salford Royal: We have investigated the circumstances around these never events and have made changes to our practices and procedures. Both of the patients received an immediate apology.
Stepping Hill: A full investigation was immediately launched after both events. As in any situation when an error occurs, additional levels of safeguards and checks were put in place which are above and beyond the standard procedures.
The Christie: The instrument was very small and the incident was graded as a '2' (minor) because the patient made a full recovery without adverse impact and went home on the expected day of discharge.
Royal Bolton: Our process for using and retrieving swabs has been thoroughly reviewed and changes made to theatre processes to make it more effective. New swab trays have been introduced... which make it easier to count swabs as they are retrieved.
Pennine Acute: Both events were fully investigated and the findings subjected to a high-level review. A number of changes had been made relating to retained swabs and instruments.
This article is courtesy from Manchester Evening News.
The preventable errors – known as ‘never events’ because the Department of Health say they should not happen – include an operation on the wrong part of a spine and swabs left in women after childbirth.
Figures obtained by the M.E.N. show 28 patients have been ‘never event’ victims in the region in just 18 months.
Central Manchester Hospitals
There were seven incidents at the Central Manchester Hospitals – which includes St Mary’s, MRI and Manchester Children’s Hospital – in 2012/13 and three so far in the current financial year.
This year’s incidents included one where a wrong mole was removed from a patient’s face.
Swabs were also left inside two patients – one after an operation in the ear, nose and throat department and one in the obstetrics and gynaecology.
Salford
There were two ‘never events’ in Salford last year including one where two drill ‘guides’ were left in a patient and another where the ‘incorrect level’ of a person’s spine was operated on.
There have been a further two events this year.
Wigan
There were also two never events at the Wrightington, Wigan and Leigh Hospitals Trust in 2012/13 – root canal work on the wrong tooth and a swab left inside a patient’s knee.
Another took place this year where a patient received an overdose of a sedative.
The trust said that incident is under investigation and the patient has since recovered.
Royal Bolton Hospital
In two high-profile cases last year, swabs were left inside two women following childbirth at the Royal Bolton Hospital.
A third case of a swab being left inside a woman also happened last year. There has been one separate ‘never event’ at the hospital this year.
Pennine Acute Hospitals Trust
There were two never events at the Pennine Acute Hospitals Trust last year – where a ‘guide wire’ was left inside a patient after a line was fitted and where a swab was left in another patient. The trust runs North Manchester General Hospital, as well as hospitals in Bury, Rochdale and Oldham.
The Christie
An instrument was also left inside a patient at the Christie Hospital last year – the only never event to have taken place at the trust.
Stockport
There were two ‘never events’ at Stepping Hill Hospital in Stockport. A swab was left in a patient following a minor operation and the wrong strength of lens was used in an ophthalmology procedure.
Pennine Care
There was one ‘never event’ last year at Pennine Care, which provides a range of mental health and community services, when packing was left in a patient’s throat after a dental procedure.
Wythenshawe and Tameside
Wythenshawe and Tameside hospitals have had no ‘never events’ in the past 18 months.
Gill Edwards, a partner in the medical negligence department at law firm Pannone, who is also a former nurse, said: “These events should never happen.
“It’s important that hospitals learn from them to prevent them from happening again. It also important that patients are informed about what steps have been taken.”
NHS England is preparing its first set of quarterly lists of never events.
A spokeswoman said: “All never events require a robust investigation to identify why the failing has occurred and to ensure preventative measures are put in place to prevent re-occurrence.”
Have you been a victim of a ‘never event’? Call us on 0161 211 2323.
What the trusts say:
Central Manchester: All never events are pro-actively reported and investigated. Every never event is analysed and we are working hard to ensure similar events do not happen in the future. This work includes liaison with other hospitals to ensure learning across the NHS.
Salford Royal: We have investigated the circumstances around these never events and have made changes to our practices and procedures. Both of the patients received an immediate apology.
Stepping Hill: A full investigation was immediately launched after both events. As in any situation when an error occurs, additional levels of safeguards and checks were put in place which are above and beyond the standard procedures.
The Christie: The instrument was very small and the incident was graded as a '2' (minor) because the patient made a full recovery without adverse impact and went home on the expected day of discharge.
Royal Bolton: Our process for using and retrieving swabs has been thoroughly reviewed and changes made to theatre processes to make it more effective. New swab trays have been introduced... which make it easier to count swabs as they are retrieved.
Pennine Acute: Both events were fully investigated and the findings subjected to a high-level review. A number of changes had been made relating to retained swabs and instruments.
This article is courtesy from Manchester Evening News.
Tuesday, 29 October 2013
Mystery object accidentally left inside surgery patient
A foreign object was accidentally left inside a patient during a surgical procedure by the Epsom and St Helier Trust.
The trust would not reveal which hospital the serious event occurred in or what the object was; despite doing so when reporting “never events”, incidents so serious they should never happen, in the past.
However, it is understood this never event occurred under local anaesthetic in one of the maternity departments in May this year. The patient was informed and received an apology.
After an initial review a serious incident investigation was launched which identified a failure of staff to follow trust policy. Following this the chief executive, Matthew Hopkins, apologised to the patient for the failure.
A spokesperson for the Epsom and St Helier Trust said: “We are absolutely committed to providing our patients with a high level of compassionate care, and the health and wellbeing of the people we treat is at the heart of all we do.
“As such, any incident that may impact on the health or safety of our patients – however rare – is taken very seriously indeed.
“In May of this year, we reported one ‘never event’, when a foreign object was retained following a surgical procedure.
“It’s important to note that incidents such as these are rare. In the last financial year, we treated more than 800,000 patients and reported one ‘never event’.
"Whilst we recognise that this is a very small proportion of the total patients treated, we will not hesitate to act upon and learn from these incidents.
“As with any untoward incident, we launched a thorough internal investigation into this matter, and as a priority, actions and measures were put in place to help prevent a similar event occurring.”
This article is courtesy from Your Local Guardian.
The trust would not reveal which hospital the serious event occurred in or what the object was; despite doing so when reporting “never events”, incidents so serious they should never happen, in the past.
However, it is understood this never event occurred under local anaesthetic in one of the maternity departments in May this year. The patient was informed and received an apology.
After an initial review a serious incident investigation was launched which identified a failure of staff to follow trust policy. Following this the chief executive, Matthew Hopkins, apologised to the patient for the failure.
A spokesperson for the Epsom and St Helier Trust said: “We are absolutely committed to providing our patients with a high level of compassionate care, and the health and wellbeing of the people we treat is at the heart of all we do.
“As such, any incident that may impact on the health or safety of our patients – however rare – is taken very seriously indeed.
“In May of this year, we reported one ‘never event’, when a foreign object was retained following a surgical procedure.
“It’s important to note that incidents such as these are rare. In the last financial year, we treated more than 800,000 patients and reported one ‘never event’.
"Whilst we recognise that this is a very small proportion of the total patients treated, we will not hesitate to act upon and learn from these incidents.
“As with any untoward incident, we launched a thorough internal investigation into this matter, and as a priority, actions and measures were put in place to help prevent a similar event occurring.”
This article is courtesy from Your Local Guardian.
Tuesday, 15 October 2013
Mum who had swab left inside her sues Royal Bolton Hospital
A mother who had a swab left inside her after a procedure in the maternity unit at the Royal Bolton Hospital is one of the claimants to launch legal action against Bolton NHS Foundation Trust.
The claim is one of eight registered against the Trust in April — an increase from March when three claims were registered.
Last year 25 claims against the trust were settled by the Clinical Negligence Scheme for Trusts, which is similar to an insurance scheme. Trusts pay a premium, which works on the level of risk.
So far this year, 21 claims have been started against the trust.
Hospital bosses encourage people to talk to the trust before launching a claim.
On possible errors, they say “medicine is not an exact science” and stressed staff work “hard to keep these to a minimum”.
In April, four claims related to delayed diagnosis or a failure to diagnose a condition properly.
Another two are linked to clinical treatment and care, one is for a birth injury and one is for a retained swab.
One in June was listed as negligent surgery and another in July as inappropriate treatment.
The retained swab was one of three cases in the maternity department between July last year and January in 2013.
This article is courtesy from The Bolton News.
The claim is one of eight registered against the Trust in April — an increase from March when three claims were registered.
Last year 25 claims against the trust were settled by the Clinical Negligence Scheme for Trusts, which is similar to an insurance scheme. Trusts pay a premium, which works on the level of risk.
So far this year, 21 claims have been started against the trust.
Hospital bosses encourage people to talk to the trust before launching a claim.
On possible errors, they say “medicine is not an exact science” and stressed staff work “hard to keep these to a minimum”.
In April, four claims related to delayed diagnosis or a failure to diagnose a condition properly.
Another two are linked to clinical treatment and care, one is for a birth injury and one is for a retained swab.
One in June was listed as negligent surgery and another in July as inappropriate treatment.
The retained swab was one of three cases in the maternity department between July last year and January in 2013.
This article is courtesy from The Bolton News.
Thursday, 10 October 2013
Doubling of NHS 'never events' never happened
Three papers report that 'never events' - the most serious of patient safety incidents - have doubled on the NHS in the past year. But they haven't - they've fallen.
Sometimes, and often with tragic consequences, NHS patient care goes badly wrong. These 'never events' are what the Department of Health (DH) terms "serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers."
It all comes down to measurement. The concept of a 'never event' has been around since 2009 but started out with just eight different 'categories'. Since 2012, the list has been expanded to cover 25 types of incident, everything from surgery in the wrong place and 'foreign objects' left in the body after an operation to badly scalding patients and allowing transferred prisoners to escape.
But, surprisingly, these aren't all recorded in one place. Formerly a never event was reported to a Strategic Health Authority (SHA) when these still existed, but some were also reported to a database called the National Reporting and Learning System (NRLS), which centrally collates patient safety incident reports. As the DH points out:
"This is a separate reporting system and the majority of these reports correspond to incidents also reported to the SHAs, so the totals cannot be added together."
In fact, the figures can differ a lot. Last year (in 2011/12) SHAs recorded 326 never events, but the NRLS only recorded 163. That 163 figure was used in the comparison with this year's 299 figure - hence the claims that incidents have 'doubled'.
Now that NHS England has confirmed the 299 figure is from the 2012/13 SHAs data, it's the 326 figure we should be using in comparison with this year.
This is all still very confusing of course. The good news is that the NHS itself is aware of this, and is developing a single system of incident reporting. From next month, NHS England will be publishing records of never events on a quarterly basis.
Waiting on corrections
While it might not be the press' fault that the earlier numbers were confused, the record still needs to be corrected. NHS England confirmed that a letter of clarification has been sent to the papers involved. We'll be keeping watch to make sure the matter is set straight.
This article is courtesy from Full Fat.
Sometimes, and often with tragic consequences, NHS patient care goes badly wrong. These 'never events' are what the Department of Health (DH) terms "serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers."
According to at least four papers last week, 299 such incidents occurred in the 2012/13 financial year. This sparked a consistent array of headlines:
(Express) - NHS blunders double
(Telegraph) - Potentially fatal 'never' errors double in year on NHS
(Mail) - Extreme 'never event' NHS blunders ... double in a year
Except this isn't the case. NHS 'never events' have not doubled. In fact, they've fallen. Full Fact got in touch with NHS England who, after some delay, clarified that the figures used by the papers were actually taking figures from two different - and non-comparable - datasets:
"The correct comparison is between data taken from the NHS serious incident management system (STEIS), which shows that the number of never events reported in the NHS was 326 in 2011/12 and around 299 in 2012/13 (note this latter figure is subject to alteration following further verification)."
So the available data (that isn't yet fully verified) actually suggests the number of never events is falling, not doubling.
What went wrong?
(Telegraph) - Potentially fatal 'never' errors double in year on NHS
(Mail) - Extreme 'never event' NHS blunders ... double in a year
Except this isn't the case. NHS 'never events' have not doubled. In fact, they've fallen. Full Fact got in touch with NHS England who, after some delay, clarified that the figures used by the papers were actually taking figures from two different - and non-comparable - datasets:
"The correct comparison is between data taken from the NHS serious incident management system (STEIS), which shows that the number of never events reported in the NHS was 326 in 2011/12 and around 299 in 2012/13 (note this latter figure is subject to alteration following further verification)."
So the available data (that isn't yet fully verified) actually suggests the number of never events is falling, not doubling.
What went wrong?
It all comes down to measurement. The concept of a 'never event' has been around since 2009 but started out with just eight different 'categories'. Since 2012, the list has been expanded to cover 25 types of incident, everything from surgery in the wrong place and 'foreign objects' left in the body after an operation to badly scalding patients and allowing transferred prisoners to escape.
But, surprisingly, these aren't all recorded in one place. Formerly a never event was reported to a Strategic Health Authority (SHA) when these still existed, but some were also reported to a database called the National Reporting and Learning System (NRLS), which centrally collates patient safety incident reports. As the DH points out:
"This is a separate reporting system and the majority of these reports correspond to incidents also reported to the SHAs, so the totals cannot be added together."
In fact, the figures can differ a lot. Last year (in 2011/12) SHAs recorded 326 never events, but the NRLS only recorded 163. That 163 figure was used in the comparison with this year's 299 figure - hence the claims that incidents have 'doubled'.
Now that NHS England has confirmed the 299 figure is from the 2012/13 SHAs data, it's the 326 figure we should be using in comparison with this year.
This is all still very confusing of course. The good news is that the NHS itself is aware of this, and is developing a single system of incident reporting. From next month, NHS England will be publishing records of never events on a quarterly basis.
Waiting on corrections
While it might not be the press' fault that the earlier numbers were confused, the record still needs to be corrected. NHS England confirmed that a letter of clarification has been sent to the papers involved. We'll be keeping watch to make sure the matter is set straight.
This article is courtesy from Full Fat.
Monday, 7 October 2013
Extreme 'never event' NHS blunders such as operating on the wrong body part or giving lethal doses of painkillers double in a year
The number of hospital mistakes deemed so serious they should never have happened has almost doubled in a single year.
There were 299 ‘never’ events in 2012/13, up from 163 in 2011/12, according to the Department of Health’s own figures.
Among 25 types of incidents are surgical instruments left in the body, operations on the wrong body part and fatal errors such as feeding tubes inserted into the lungs and patients given lethal doses of painkillers.
A list of these errors, by hospital, will be published so patients can see where the highest number occur.
NHS England – the organisation in charge of the health service – will release the data four times a year starting from next month.
There are 25 different types of ‘never events’ including surgery on the wrong body part, patients being given lethal doses of painkillers and mothers dying during caesareans.
Others include feeding tubes inserted into the lungs rather than the stomach and staff muddling up patients giving them the wrong treatment or operation.
But medical negligence lawyers believe that thousands of these mistakes occur each year but staff often try and cover them up in case patients try to sue.
NHS England could not explain why the numbers had increased so starkly and said another organisation had been responsible for collecting them in the past.
Mike Durkin, the body’s director of patient safety said: ‘NHS England intends to begin publishing more detailed data on never events on a more regular basis very soon, providing more frequent information on the numbers and kinds of never events that occur in the NHS as part of its wider commitment to transparency but also to stimulate more learning and preventative action in the NHS.
‘Every single never event is one too many and, as Don Berwick (the Government’s tsar on preventing harm) made clear in his recent report, we need to openly and publicly report and address safety problems, not so that people can lay blame inappropriately, but so that we can fully understand and therefore learn more from the safety problems that the NHS, like all healthcare systems, faces.’
One grieving relative described how nurses had mistakenly inserted a feeding tube into her mother’s lungs instead of her stomach.
Speaking anonymously, the victim said staff had also failed to carry out an x-ray to check it was in the right place.
In a recent interview with the BBC she said: ‘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,’
‘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.’
Shadow health secretary Andy Burnham said: ‘These worrying figures reveal an NHS cutting too many corners and sailing dangerously close to the wind.
‘Ministers have been repeatedly warned that too many hospitals in England do not have enough staff to provide care. Their failure to act has left wards under-staffed and nurses over-stretched. That explains why so many nurses say they have considered resigning.
‘The warning signs of an NHS under intense pressure are growing day by day and David Cameron cannot continue to ignore them. He must act to halt the job losses and ensure all hospitals in England have enough staff on the wards to provide safe care.’
This article is courtesy from the Daily Mail.
There were 299 ‘never’ events in 2012/13, up from 163 in 2011/12, according to the Department of Health’s own figures.
Among 25 types of incidents are surgical instruments left in the body, operations on the wrong body part and fatal errors such as feeding tubes inserted into the lungs and patients given lethal doses of painkillers.
A list of these errors, by hospital, will be published so patients can see where the highest number occur.
NHS England – the organisation in charge of the health service – will release the data four times a year starting from next month.
There are 25 different types of ‘never events’ including surgery on the wrong body part, patients being given lethal doses of painkillers and mothers dying during caesareans.
Others include feeding tubes inserted into the lungs rather than the stomach and staff muddling up patients giving them the wrong treatment or operation.
But medical negligence lawyers believe that thousands of these mistakes occur each year but staff often try and cover them up in case patients try to sue.
NHS England could not explain why the numbers had increased so starkly and said another organisation had been responsible for collecting them in the past.
Mike Durkin, the body’s director of patient safety said: ‘NHS England intends to begin publishing more detailed data on never events on a more regular basis very soon, providing more frequent information on the numbers and kinds of never events that occur in the NHS as part of its wider commitment to transparency but also to stimulate more learning and preventative action in the NHS.
‘Every single never event is one too many and, as Don Berwick (the Government’s tsar on preventing harm) made clear in his recent report, we need to openly and publicly report and address safety problems, not so that people can lay blame inappropriately, but so that we can fully understand and therefore learn more from the safety problems that the NHS, like all healthcare systems, faces.’
One grieving relative described how nurses had mistakenly inserted a feeding tube into her mother’s lungs instead of her stomach.
Speaking anonymously, the victim said staff had also failed to carry out an x-ray to check it was in the right place.
In a recent interview with the BBC she said: ‘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,’
‘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.’
Shadow health secretary Andy Burnham said: ‘These worrying figures reveal an NHS cutting too many corners and sailing dangerously close to the wind.
‘Ministers have been repeatedly warned that too many hospitals in England do not have enough staff to provide care. Their failure to act has left wards under-staffed and nurses over-stretched. That explains why so many nurses say they have considered resigning.
‘The warning signs of an NHS under intense pressure are growing day by day and David Cameron cannot continue to ignore them. He must act to halt the job losses and ensure all hospitals in England have enough staff on the wards to provide safe care.’
This article is courtesy from the Daily Mail.
Wednesday, 18 September 2013
Should we change our attitude towards 'never events'?
Twenty-five errors in the health service are considered so intolerable and inexcusable that they have been designated 'never events'. They include wrong-site surgery, retained foreign objects and administering chemotherapy by the wrong route.
When a never event occurs, the organisation concerned must follow national procedures for reporting and investigating what happened and may pay a significant financial penalty. The object of the policy introduced in 2009 is to encourage greater organisational focus on specific serious safety issues. The problem with categorising certain incidents as never events is that it may divert attention from the most important goal of improving patient safety across the board. The term is also misleading because these events do occur, usually because of a combination of chance and human error, factors that can never be totally eliminated. In his positively received report into NHS patient safety Professor Don Berwick states: "'Zero Harm' is a bold and worthy aspiration, [but] the scientifically correct goal is 'continual reduction'. All in the NHS should understand that safety is a continually emerging property, and that the battle for safety is never 'won'; rather, it is always in progress."
In May 2013 a BBC investigation identified 762 never events in four years, including 322 retained items and 73 misplaced nasogastric feeding tubes. I do not believe the categorisation never events is helpful. This is not to dismiss the distress these errors cause to patients and their families, but the term and the financial penalties create a stigma for individuals and organisations, which may not be conducive to a culture that should promote reporting and learning from mistakes. When our members, who are 50% of UK GPs and hospital doctors, approach us for advice about what to do if there has been a mistake in a patient's care or treatment, we advise them to ensure the patient receives a sincere apology, together with an explanation of what went wrong and how it will be put right. Irrespective of whether the incident was a never event, it is vital that there is a full investigation and that steps are taken to avoid the incident happening again.
For patients who are harmed, the last thing on their minds is probably whether it was a never event. There are incidents in which patients are harmed that fall outside the classification. One example is where patients have been given a drug, such as penicillin, to which they have a known allergy. The consequences of this could be anaphylactic shock and even death and in many cases the error could have been prevented by taking and recording of a medical history, checking records before administering medication and checking if the patient is wearing a red wristband. These preventable errors must be treated as seriously as a never event but there is a risk they may not get the same attention.
Medicine, even when properly and carefully practised, is not a zero-harm or a zero-risk profession.
Preventable things can and do go wrong, sometimes with severe consequences for patients and to the distress of the healthcare professionals involved.
Berwick argues there is a need for a transparent culture within the NHS where mistakes are reported and learning is shared to improve patient safety. Patients who have suffered harm because of any medical error should rightly expect that what happened to them has been the subject of a thorough investigation to determine what happened, why and what lessons have to be learned. Wouldn't it be better to concentrate on this than on determining whether an incident classifies as a never event?
This article is courtesy of theguardian.
When a never event occurs, the organisation concerned must follow national procedures for reporting and investigating what happened and may pay a significant financial penalty. The object of the policy introduced in 2009 is to encourage greater organisational focus on specific serious safety issues. The problem with categorising certain incidents as never events is that it may divert attention from the most important goal of improving patient safety across the board. The term is also misleading because these events do occur, usually because of a combination of chance and human error, factors that can never be totally eliminated. In his positively received report into NHS patient safety Professor Don Berwick states: "'Zero Harm' is a bold and worthy aspiration, [but] the scientifically correct goal is 'continual reduction'. All in the NHS should understand that safety is a continually emerging property, and that the battle for safety is never 'won'; rather, it is always in progress."
In May 2013 a BBC investigation identified 762 never events in four years, including 322 retained items and 73 misplaced nasogastric feeding tubes. I do not believe the categorisation never events is helpful. This is not to dismiss the distress these errors cause to patients and their families, but the term and the financial penalties create a stigma for individuals and organisations, which may not be conducive to a culture that should promote reporting and learning from mistakes. When our members, who are 50% of UK GPs and hospital doctors, approach us for advice about what to do if there has been a mistake in a patient's care or treatment, we advise them to ensure the patient receives a sincere apology, together with an explanation of what went wrong and how it will be put right. Irrespective of whether the incident was a never event, it is vital that there is a full investigation and that steps are taken to avoid the incident happening again.
For patients who are harmed, the last thing on their minds is probably whether it was a never event. There are incidents in which patients are harmed that fall outside the classification. One example is where patients have been given a drug, such as penicillin, to which they have a known allergy. The consequences of this could be anaphylactic shock and even death and in many cases the error could have been prevented by taking and recording of a medical history, checking records before administering medication and checking if the patient is wearing a red wristband. These preventable errors must be treated as seriously as a never event but there is a risk they may not get the same attention.
Medicine, even when properly and carefully practised, is not a zero-harm or a zero-risk profession.
Preventable things can and do go wrong, sometimes with severe consequences for patients and to the distress of the healthcare professionals involved.
Berwick argues there is a need for a transparent culture within the NHS where mistakes are reported and learning is shared to improve patient safety. Patients who have suffered harm because of any medical error should rightly expect that what happened to them has been the subject of a thorough investigation to determine what happened, why and what lessons have to be learned. Wouldn't it be better to concentrate on this than on determining whether an incident classifies as a never event?
This article is courtesy of theguardian.
Sunday, 15 September 2013
NHS England to puNHS England to publish trust-by-trust 'never events' listblish trust-by-trust 'never events' list
NHS England is to publish quarterly lists of all the “never events” – the worst preventable mistakes – recorded in the NHS, broken down by trust.
It will produce its first online list recording the number and type of incidents at each trust this October. It has collected the data from trusts since the start of 2013-14 financial year, in April.
The Department of Health has defined 25 types of never event, including surgery on the wrong area, misplaced nasogastric tubes and “maladministration of insulin”.
The BBC has previously reported that between 2009 and 2012 there had been 762 never events across the NHS, including 214 categorised as “wrong site surgery” and 322 as “retained foreign object post operation”.
Mike Durkin, NHS England’s director of patient safety, said the idea was to offer more detail on top of existing annual data that records the number of never events in different types of care setting.
“NHS England intends to begin publishing more detailed data on never events on a more regular basis very soon, providing more frequent information on the numbers and kinds of never events that occur in the NHS as part of its wider commitment to transparency, but also to stimulate more learning and preventative action,” he said.
“We need to openly and publicly report and address safety problems, not so that people can lay blame inappropriately, but so that we can fully understand and therefore learn more from the safety problems that the NHS, like all healthcare systems, faces,” he added.
NHS England revealed the move in response to a Freedom of Information Act request by Nursing Times’ sister title Health Service Journal.
This article is courtesy of the Nursing Times.
It will produce its first online list recording the number and type of incidents at each trust this October. It has collected the data from trusts since the start of 2013-14 financial year, in April.
The Department of Health has defined 25 types of never event, including surgery on the wrong area, misplaced nasogastric tubes and “maladministration of insulin”.
The BBC has previously reported that between 2009 and 2012 there had been 762 never events across the NHS, including 214 categorised as “wrong site surgery” and 322 as “retained foreign object post operation”.
Mike Durkin, NHS England’s director of patient safety, said the idea was to offer more detail on top of existing annual data that records the number of never events in different types of care setting.
“NHS England intends to begin publishing more detailed data on never events on a more regular basis very soon, providing more frequent information on the numbers and kinds of never events that occur in the NHS as part of its wider commitment to transparency, but also to stimulate more learning and preventative action,” he said.
“We need to openly and publicly report and address safety problems, not so that people can lay blame inappropriately, but so that we can fully understand and therefore learn more from the safety problems that the NHS, like all healthcare systems, faces,” he added.
NHS England revealed the move in response to a Freedom of Information Act request by Nursing Times’ sister title Health Service Journal.
This article is courtesy of the Nursing Times.
Saturday, 14 September 2013
Extreme 'never event' NHS blunders such as operating on the wrong body part or giving lethal doses of painkillers double in a year
The number of hospital mistakes deemed so serious they should never have happened has almost doubled in a single year.
There were 299 ‘never’ events in 2012/13, up from 163 in 2011/12, according to the Department of Health’s own figures.
Among 25 types of incidents are surgical instruments left in the body, operations on the wrong body part and fatal errors such as feeding tubes inserted into the lungs and patients given lethal doses of painkillers.
A list of these errors, by hospital, will be published so patients can see where the highest number occur.
NHS England – the organisation in charge of the health service – will release the data four times a year starting from next month.
There are 25 different types of ‘never events’ including surgery on the wrong body part, patients being given lethal doses of painkillers and mothers dying during caesareans.
Others include feeding tubes inserted into the lungs rather than the stomach and staff muddling up patients giving them the wrong treatment or operation.
But medical negligence lawyers believe that thousands of these mistakes occur each year but staff often try and cover them up in case patients try to sue.
NHS England could not explain why the numbers had increased so starkly and said another organisation had been responsible for collecting them in the past.
Mike Durkin, the body’s director of patient safety said: ‘NHS England intends to begin publishing more detailed data on never events on a more regular basis very soon, providing more frequent information on the numbers and kinds of never events that occur in the NHS as part of its wider commitment to transparency but also to stimulate more learning and preventative action in the NHS.
‘Every single never event is one too many and, as Don Berwick (the Government’s tsar on preventing harm) made clear in his recent report, we need to openly and publicly report and address safety problems, not so that people can lay blame inappropriately, but so that we can fully understand and therefore learn more from the safety problems that the NHS, like all healthcare systems, faces.’
One grieving relative described how nurses had mistakenly inserted a feeding tube into her mother’s lungs instead of her stomach.
Speaking anonymously, the victim said staff had also failed to carry out an x-ray to check it was in the right place.
In a recent interview with the BBC she said: ‘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,’
‘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.’
Shadow health secretary Andy Burnham said: ‘These worrying figures reveal an NHS cutting too many corners and sailing dangerously close to the wind.
‘Ministers have been repeatedly warned that too many hospitals in England do not have enough staff to provide care. Their failure to act has left wards under-staffed and nurses over-stretched. That explains why so many nurses say they have considered resigning.
‘The warning signs of an NHS under intense pressure are growing day by day and David Cameron cannot continue to ignore them. He must act to halt the job losses and ensure all hospitals in England have enough staff on the wards to provide safe care.’
This article is courtesy of the Daily Mail.
There were 299 ‘never’ events in 2012/13, up from 163 in 2011/12, according to the Department of Health’s own figures.
Among 25 types of incidents are surgical instruments left in the body, operations on the wrong body part and fatal errors such as feeding tubes inserted into the lungs and patients given lethal doses of painkillers.
A list of these errors, by hospital, will be published so patients can see where the highest number occur.
NHS England – the organisation in charge of the health service – will release the data four times a year starting from next month.
There are 25 different types of ‘never events’ including surgery on the wrong body part, patients being given lethal doses of painkillers and mothers dying during caesareans.
Others include feeding tubes inserted into the lungs rather than the stomach and staff muddling up patients giving them the wrong treatment or operation.
But medical negligence lawyers believe that thousands of these mistakes occur each year but staff often try and cover them up in case patients try to sue.
NHS England could not explain why the numbers had increased so starkly and said another organisation had been responsible for collecting them in the past.
Mike Durkin, the body’s director of patient safety said: ‘NHS England intends to begin publishing more detailed data on never events on a more regular basis very soon, providing more frequent information on the numbers and kinds of never events that occur in the NHS as part of its wider commitment to transparency but also to stimulate more learning and preventative action in the NHS.
‘Every single never event is one too many and, as Don Berwick (the Government’s tsar on preventing harm) made clear in his recent report, we need to openly and publicly report and address safety problems, not so that people can lay blame inappropriately, but so that we can fully understand and therefore learn more from the safety problems that the NHS, like all healthcare systems, faces.’
One grieving relative described how nurses had mistakenly inserted a feeding tube into her mother’s lungs instead of her stomach.
Speaking anonymously, the victim said staff had also failed to carry out an x-ray to check it was in the right place.
In a recent interview with the BBC she said: ‘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,’
‘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.’
Shadow health secretary Andy Burnham said: ‘These worrying figures reveal an NHS cutting too many corners and sailing dangerously close to the wind.
‘Ministers have been repeatedly warned that too many hospitals in England do not have enough staff to provide care. Their failure to act has left wards under-staffed and nurses over-stretched. That explains why so many nurses say they have considered resigning.
‘The warning signs of an NHS under intense pressure are growing day by day and David Cameron cannot continue to ignore them. He must act to halt the job losses and ensure all hospitals in England have enough staff on the wards to provide safe care.’
This article is courtesy of the Daily Mail.
Thursday, 5 September 2013
Medical error ‘robbed me of a year of my life’
For 18 days, the burning, oozing wound on Lynn Burkitt’s chest grew larger and more painful.
The Medicine Hat woman, who’d recently undergone a double mastectomy, made multiple trips to the emergency room to try to figure out what was wrong.
“It was extreme pain. The smell was gross, the discharge was gross,” she said.
It wasn’t until she’d undergone another surgery that she found out what happened: the doctor who’d performed her mastectomy left two rolls of sterile gauze inside and, with no one taking proper care of the wound, the material was now festering inside her chest.
Burkitt, 52, said she’s since learned that a series of mishap and miscommunications meant that no one — including the homecare nurses taking care of her, the ER doctors or any member of her care team — realized the surgeon had left the gauze inside her wound.
She said she is still recovering from the June 2012 experience and wants to see Alberta Health Services put new safeguards in place so others don’t have to endure the same pain.
“I want answers on what changes they’re going to do, because they said ‘We’re going to come up with new processes.’ ”
In a statement, AHS said a patient safety review at the Medicine Hat hospital “focused on continuity of care, communication between and among caregivers, and smoother transfer of patient care between programs (and) departments.”
Changes have since been made, including a new “visual alert” on a patient chart for unusual or special-care needs, and ongoing efforts to improve communication between caregivers and different departments.
“We have apologized to Ms. Burkitt personally and in writing and we continue to wish her the best in her recovery,” according to the AHS statement.
Burkitt said she chose to undergo a double mastectomy in June 2012 after she was diagnosed with an early stage breast cancer, then soon had another surgery to deal with infection.
She said the homecare nurses who took care of her after the second procedure did the best they could when her wound flared up, but simply didn’t know about the gauze.
According to Burkitt, she was eventually prescribed antibiotics after making multiple trips to the emergency ward.
She said it shouldn’t have taken a surgery for medical staff to read the mastectomy surgeon’s operative report that said the gauze was used on her wound.
The Medicine Hat woman said she’s been trying to get answers from AHS for months on what happened. While representatives assigned to her case told her last fall they’d do a full investigation, she didn’t hear back. It was only after Burkitt took her story public that she said she heard the results of the probe.
“I don’t want anybody else to go through this,” said Burkitt.
“There has to be a policy in place when somebody has packing put inside of them that it is marked on the chart, or people read the chart. There’s no communication that goes on between the different departments.”
“They robbed me of over a year of my life.”
This article is courtesy of the Calgary Herald.
The Medicine Hat woman, who’d recently undergone a double mastectomy, made multiple trips to the emergency room to try to figure out what was wrong.
“It was extreme pain. The smell was gross, the discharge was gross,” she said.
It wasn’t until she’d undergone another surgery that she found out what happened: the doctor who’d performed her mastectomy left two rolls of sterile gauze inside and, with no one taking proper care of the wound, the material was now festering inside her chest.
Burkitt, 52, said she’s since learned that a series of mishap and miscommunications meant that no one — including the homecare nurses taking care of her, the ER doctors or any member of her care team — realized the surgeon had left the gauze inside her wound.
She said she is still recovering from the June 2012 experience and wants to see Alberta Health Services put new safeguards in place so others don’t have to endure the same pain.
“I want answers on what changes they’re going to do, because they said ‘We’re going to come up with new processes.’ ”
In a statement, AHS said a patient safety review at the Medicine Hat hospital “focused on continuity of care, communication between and among caregivers, and smoother transfer of patient care between programs (and) departments.”
Changes have since been made, including a new “visual alert” on a patient chart for unusual or special-care needs, and ongoing efforts to improve communication between caregivers and different departments.
“We have apologized to Ms. Burkitt personally and in writing and we continue to wish her the best in her recovery,” according to the AHS statement.
Burkitt said she chose to undergo a double mastectomy in June 2012 after she was diagnosed with an early stage breast cancer, then soon had another surgery to deal with infection.
She said the homecare nurses who took care of her after the second procedure did the best they could when her wound flared up, but simply didn’t know about the gauze.
According to Burkitt, she was eventually prescribed antibiotics after making multiple trips to the emergency ward.
She said it shouldn’t have taken a surgery for medical staff to read the mastectomy surgeon’s operative report that said the gauze was used on her wound.
The Medicine Hat woman said she’s been trying to get answers from AHS for months on what happened. While representatives assigned to her case told her last fall they’d do a full investigation, she didn’t hear back. It was only after Burkitt took her story public that she said she heard the results of the probe.
“I don’t want anybody else to go through this,” said Burkitt.
“There has to be a policy in place when somebody has packing put inside of them that it is marked on the chart, or people read the chart. There’s no communication that goes on between the different departments.”
“They robbed me of over a year of my life.”
This article is courtesy of the Calgary Herald.
Subscribe to:
Posts (Atom)