Medical bosses investigate three serious mistakes
Doncaster Royal Infirmary
MEDICAL bosses are investigating after three serious medical blunders were made over a two week period - including a swab being left inside a woman after she gave birth.
Doncaster and Bassetlaw Hospitals NHS Foundation Trust said the mistakes, which also include a wrong part fitted in a hip replacement and a piece of wire left inside a patient after surgery were ‘never events’ and happened in a two week period at the end of March to April.
Prior to the incidents the trust, which runs Doncaster Royal Infirmary, Mexborough Montagu Hospital, Tickhil Road Hospital and Bassetlaw Hospital, had only recorded one such ‘never event’.
Bosses at the trust have expressed their concerned about the latest run of incidents.
Ray Cuschieri, deputy medical director for the trust, said: “Never events are by definition things that shouldn’t occur, so we have taken them extremely seriously.
“Fortunately, none of the three patients came to harm other than needing further procedures to correct the errors and we have kept them fully informed of our findings.
“We have carried out very detailed investigations to find out what went wrong.
“These events came about because individuals hadn’t followed clinical protocols and policies correctly.
“We are taking appropriate action in each case, but have also raised awareness right across the trust of never events and the vital importance of following internal policies and procedures as well as national clinical guidelines. They are there for a reason – to keep patients safe.”
The first error happened when doctors carried out a three-piece hip replacement, but one of the parts installed was not the correct size. The trust said the checks required were not carried out and was identified shortly after surgery.
The patient had surgery the following day to rectify the situation.
The second incident saw a guidewire left inside a patient during an operation, which was used to help insert a cannula into a large vein supplying the heart, but was not removed afterwards.
A spokesman said this was a known risk so staff should always check and confirm the wire has been removed.
The error was identified eight hours later on an x-ray and the wire was removed an hour afterwards.
The third error saw a swab left inside a new mum following the birth of her baby.
The error was identified when she visited her GP around three weeks later because of a ‘heavy’ feeling. On examining the patient, the GP discovered the swab and removed it.
The only previous so-called ‘never event’ at the trust happened last year, when doctors at the DRI pumped fluid into a patient’s lungs by mistake. The patient who was affected by the mistake has since died - but the death was not connected to the error.
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Tuesday 21 May 2013
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