Action needed over appalling hospital ‘never event’ error figures

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Action needed over appalling hospital ‘never event’ error figures

10th May 2013

A leading medical negligence specialist has said it is ‘totally unacceptable’ that in the last four years alone more than 750 patients in English hospitals have suffered surgical errors of the kind the Department of Health says should simply never happen.

Jacqui Hayat, head of the London Medical Negligence department at Fentons Solicitors LLP, was speaking after a BBC investigation used Freedom of Information requests to reveal the extent of so-called ‘never events’ across NHS Trusts in England.

“Never events are serious, largely preventable patient safety incidents that the Department of Health deem so severe they should just not happen, ever,” said Jacqui, a partner with the firm. “They include fundamental failings such as performing surgery on the wrong body part or mistakenly leaving medical instruments or swabs inside patients post-surgery.

“It is both appalling and totally unacceptable that this investigation has found hundreds of patients in English hospitals are continuing to fall victim to such potentially catastrophic errors,” she added. “If the available preventative measures we have in place in our hospitals are implemented correctly, these types of incident should simply never occur.

“The fact that Primary Care Trusts are required to monitor the occurrence of ‘never events’ within the services they commission and publicly report them on an annual basis, means that not enough is being done to educate staff on better practice,” said Jacqui.

The Department of Health has categorised 25 incidents that should never happen if national safety recommendations are correctly adhered to by medical staff. The BBC investigation revealed that the majority of these errors fell into four main categories.

In the last four years, there were 322 cases of instruments or swabs being left inside patients during surgery; 214 cases of operations being performed on the wrong body part; 73 cases of feeding and medication tubes being accidentally inserted into patients' lungs; and 58 cases of implants or prostheses being wrongly fitted.

“Although these figures paint a negative portrait of failing patient care in our hospitals, it is important to put the numbers in context and recognise that each year on average in England alone there are more than 4.5 million hospital admissions that require surgery,” said Jacqui.

“Having said that, the NHS state that the risk of a ‘never event’ happening to a patient is one in 20,000. Regardless of this, the fact is any serious medical blunder of this kind can have devastating consequences and the thinking regarding patient care must remain that even one event of this kind is one too many.

“The statistics revealed by the BBC investigation are of course shocking, but we also need to look at the bigger picture,” said Jacqui, “namely how to more efficiently collate data regarding these never events so that health practitioners can do more to educate and promote better practice, not only amongst individuals but across all the Trusts involved.”

NHS England has admitted the figures are too high and that new measures have been introduced to ensure patient safety.

Read more at BBC News