They call them ‘never events’… yet they keep on happening in the NHS.
In the light of a recent BBC investigation Arti Shah, of our London office, explains just how easy avoiding ‘preventable mistakes’ should be for the NHS …
This week a BBC investigation reported 750 incidents of ‘preventable mistakes’ having occurred over the last four years. Classified as ‘never events’, on the basis that they are so serious that they should never happen, the list included:
- 322 cases of foreign objects left inside patients during operations
- 214 cases of surgery on the wrong body part
- 73 cases of tubes, which are used for feeding patients or for medication, being inserted into patients’ lungs
- 58 cases of wrong implants or prostheses being fitted.
In total, a list of 25 incidents have been identified. However it’s feared that not all incidents are reported, and that the true number may be higher.
Having dealt with cases involving ‘retained objects’ following procedures, and reviewing the reports that have been produced as a result, it’s difficult to see how cases like this still occur. Especially when they can be avoided simply by counting instruments at the beginning of a procedure and ensuring that the same number are present at the end. Similarly, marking the correct side of the body prior to operating seems a sensible precaution to avoid surgery on the wrong side.
It’s important to recognise that this represents only a small number of cases, given that the NHS deals with some 4.6 million admissions to hospital which require surgery. But when the Director of Patient Safety comments that ‘One is too many in any week, in any day, in any hospital ’, I have to agree.