healthmedicinet

A silicone object left inside someone, a patient falling from a window and the wrong person undergoing an exploratory procedure are among “never events” which have happened in Welsh hospitals.

These are “largely preventable patient safety incidents” that should not happen if proper measures are in place.

There were 60 of these incidents in Wales’ seven health boards from April 2012 to present.

The Welsh Government said: “Patient safety in Wales is paramount.”

Items mistakenly left inside patients following surgery or procedures include vaginal swabs, a surgical blade and a silicone object.

Wrong site surgeries included the wrong joint being injected, the wrong side pleural biopsy, operating on the wrong spinal disc and the incorrect tooth being removed.

‘Open safety culture’

Incorrect implants or prosthesis included a hip replacement, a lens and a pacemaker.

One person was also able to fall from a window which was within reach of patients at floor level and could be opened without the use of a tool.

A Welsh Government spokesman said: “Every year, hundreds of thousands of people receive high-quality, safe care in the Welsh NHS.

“However, in an increasingly complicated and modern healthcare system, problems can unfortunately happen.

“When problems do occur, NHS staff are encouraged to report all incidents so they can be investigated openly to promote learning and provide open feedback to patients and their families as part of our commitment to an open safety culture.”

Between 2012 and 2016, Abertawe Bro Morgannwg health board had 15 “never events”, Aneurin Bevan had eight, Betsi Cadwaladr had 15, Cardiff Vale had 13, Hywel Dda had four and Cwm Taf had five. There were none in Powys.

NHS Wales publishes an annual list online of all the mistakes made.

Never events 2012-16

Abertawe Bro Morgannwg

• Retained foreign object – swab (x4)
• Wrong implant – prosthesis, right implant into left knee
• Wrong implant/prosthesis – incorrect femoral head implant used
• Wrong implant/prosthesis – incorrect valve used
• Misplaced nasogastric tube
• Misplaced naso or oro-gastric tubes
• Retained foreign object (x2)
• Wrong implant/prosthesis (x2)
• Wrong site surgery
• Wrong site surgery – wrong toe incised

Aneurin Bevan

• Wrong implant/prosthesis – wrong size lens
• Wrong implant/prosthesis
• Retained foreign object – swab (x2)
• Retained foreign object (x2)
• Retained foreign object – tip of needle identified post-operatively
• Misplaced naso or oro-gastric tubes

Betsi Cadwaladr

• Retained foreign object – swab (x2)
• Misidentification of patient – wrong patient had exploratory procedure
• Misidentification of patient – maladministration of insulin (no wristband in place)
• Maladministration of insulin
• Wrong gas administered – seal not removed on oxygen cylinder
• Fall from poorly restricted window
• Misplaced naso or oro-gastric tubes
• Overdose of insulin due to abbreviations or incorrect device
• Wrong route administration of medication – oral medication given intravenously
• Wrong site surgery (x2)
• Wrong site surgery – wrong tooth removed
• Wrong site surgery – wrong part of organ identified (rectified during procedure)
• Wrong site surgery – left side prosthesis implanted instead of right

Cardiff Vale

• Misplaced nasogastric tube
• Retained foreign object – silicone object
• Wrong site surgery – wrong scar site identified for procedure
• Wrong site surgery – initial skin incision incorrectly made (rectified during procedure)
• Intra-operative air embolism
• Retained foreign object – swab
• Retained foreign object – tracheostomy cleaner
• Retained foreign object (x4)
• Wrong implant/prosthesis
• Wrong site surgery

Cwm Taf

• Misplaced nasogastric tube
• Retained foreign object – swab
• Entrapment in bedrails – arm trapped in cot
• Wrong implant/prosthesis
• Medication administered intravenously instead of via epidural

Hywel Dda

• Retained foreign object – swab
• Misidentification of patient – histopathology specimens (study of changes in tissues caused by disease)
• Wrong site surgery – incorrect hernia repaired
• Retained foreign object post-procedure