Another ‘never event’ Sparks Telford Hospital Probe

A serious medical "never event" occurred in an operating theatre at Telford's Princess Royal Hospital last month, it has been revealed.


Another ‘never event’ Sparks Telford Hospital Probe

It involved a 'retained swab' during an ear, nose and throat procedure, Shrewsbury and Telford Hospital NHS Trust's (SaTH) board was told.

Never events are named so because they are incidents that guidelines say should never happen.

A report to the trust board said no harm was caused to the patient, but hospital bosses say it has led to a meeting being called for operating theatre staff.

It is the fourth never event to be recorded in the last 12 months by the trust, which runs PRH and Royal Shrewsbury Hospital.

The report by Dr David Lee, chairman of the quality and safety assurance committee, said: "Unfortunately, there has been a further 'Never Event' occurring within the operating theatre at Princess Royal Hospital.

"This involved a retained swab during an ENT (ear, nose and throat) procedure.

"The problem was identified rapidly within the recovery room.

"There is no reported harm to the patient.

"The investigation is being led by an independent clinical safety expert with support from SaTH’s experts in human factors."

Chief executive of the trust, Simon Wright, said a meeting had been called for theatre staff to discuss the safety of patients during surgery.

Other never events

It comes after the trust recorded another never event in May which involved 'wrong site' surgery.

A quality governance report, which was put before the trust board on Thursday, said SaTH had taken immediate actions in relation to that incident.

It says a lead investigator was appointed who will be supported by an external expert, and there has been thematic analysis of the previous never events in the operating theatres over the last two years.

Wrong-site surgery can involve surgery being performed on the wrong side or site of the body, the wrong surgical procedure or surgery on the wrong patient.

Exact details of the incident were not disclosed.

A never event recorded in February was to do with the administration of oramorph – a medication that should be taken orally but was given through the IV route.

Last October there was also a never event in ophthalmology, which deals with the diagnosis, treatment and prevention of diseases of the eye and visual system.

The incident involved a locum surgeon implanting the wrong lens on a patient following cataract surgery.

Dr Edwin Borman, medical director, said at the time that the impact on the patient had been “negligible”.


Source: Lisa O'Brien, Shropshire Star


Another ‘never event’ Sparks Telford Hospital Probe

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