NHS Staff Blunders Harm 25 Patients a Month, Figures Show

'Never events' including wrong patient receiving surgery happened 148 times in England between April and September


Twenty-five patients a month are harmed by NHS staff blunders such as operating on the wrong part of their body, giving them too many drugs or mistakenly putting a feeding tube into their lungs, new official figures have revealed.

"Never events" – errors which should never happen – also include patients receiving the wrong treatment or the wrong blood type, and even the wrong patient undergoing surgery.

NHS England has published unprecedented detail about how many such mistakes occur, and where, and what they involve. Robert Francis QC recommended the move earlier this year in his report into the Mid Staffordshire hospital care scandal, which demanded that the NHS become much more open.

In all, 148 "never events" occurred in 102 hospital trusts in England between April and September. Of those, 69 involved a foreign object such as a surgical swab being left inside a patient who had undergone surgery and another 37 the wrong part of the patient's body being operated on. Another 21 patients were given the wrong implant or prosthesis, seven were given inappropriate doses of methotrexate, a commonly used cancer drug, and five had a naso-gastric feeding tube wrongly placed into their lungs.

In all cases the patient suffered some avoidable harm. However, although NHS England emphasised its honesty in disclosing the information, it said it did not know how many of the 14 patients concerned had died in 14 separate incidents that resulted in "death or severe harm", or even what level of damage they suffered, even though some happened up to eight months ago.

They included two cases of patients being transfused with the wrong type of blood, one being given an overdose, and another receiving the wrong gas. One of the 14, though, was a woman who died as a result of complications after giving birth in what was classed as a "maternal death due to postpartum haemorrhage after elective caesarean section".

The 37 wrong-site surgeries included cases in which one woman had the wrong fallopian tube removed after an ectopic pregnancy and another had a fallopian tube removed instead of her appendix. NHS England's list also cites cases in which the wrong patient underwent procedures including a colonoscopy and the removal of some or all of his prostate.

The 148 never events are about the same as the figures for all of 2012-13, when 290 occurred. NHS England stressed that these incidents were extremely rare, occurring only once in every 20,000 procedures. Four of the 148 occurred at hospitals run by Newcastle upon Tyne hospitals NHS foundation trust, the most anywhere. Eight trusts had three each, but 137 recorded none at all.

Dr Mike Durkin, NHS England's national director of patient safety, said that while every such event put a patient at risk of avoidable harm, there needed to be an honest debate about the risks inherent in healthcare.

"One of those risks – with the best will in the world and the best doctors, nurses and other healthcare professionals in the world – is that things can go wrong, and mistakes can be made," he said.


Source: Denis Campbell, health correspondent, The Guardian



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