Patient given wrong blood type during transfusion, as East and North Herts NHS Trust reveals series of 'never events'
PUBLISHED: 06:57 08 June 2018
A patient was given the wrong blood type during a transfusion - one of six serious incidents which highlight potential weaknesses in how the East and North Herts NHS Trust manages fundamental safety processes.
The Trust - which runs Lister Hospital in Stevenage, the QEII in Welwyn Garden City, Hertford County, and Mount Vernon Cancer Centre in Middlesex - recorded six ‘never events’ in 2017/18, compared to just one the previous year.
‘Never events’ have the potential to cause serious harm, or even death, and are avoidable.
One Trust patient had the wrong finger operated on, while another was fed fluids via a feeding tube that was placed in the lung rather than the stomach.
A suture needle - used to stitch an open wound closed - was left inside a patient after she had given birth at Lister Hospital’s maternity unit.
A gallstone retrieval bag was left inside a patient following surgery, and another patient had a guidewire - used to help insert a central line to allow fluids and medication to be given - left in place by mistake.
‘Never events’ are different from other serious incidents as the overriding principle of having the ‘never events’ list is that even a single ‘never event’ acts as a red flag that an organisation’s systems for implementing existing safety advice or alerts might not be robust.
The foreword to the Never Events Policy and Framework states: “Never events are key indicators that there have been failures to put in place the required systemic barriers to error and their occurrence can tell commissioners something fundamental about the quality, care and safety processes in an organisation.”
A Trust spokesman said: “Never events are incidents that across the NHS are considered as being avoidable should available preventative measures be implemented.
“Last year, the Trust recorded six never events – which is six too many, but should be seen in the context of over 720,000 patient contacts across our hospitals over the same period. That means the vast majority of our patients received high quality, safe and effective care but, where incidents were reported, they were investigated thoroughly and actions taken to put the right preventative measures in place – including ensuring our staff were aware of what happened and what needed to change.”