Wrong site surgery among 'never events' at hospital trust

Lister Hospital in Stevenage

The East and North Hertfordshire NHS Trust, which runs Lister Hospital in Stevenage and the New QEII Hospital in Welwyn Garden City, declared five never events in 2021/22 - Credit: Courtesy of the East and North Hertfordshire NHS Trust

Four incidents of wrong site surgery and a retained dressing after an operation were 'never events' recorded by the East and North Hertfordshire NHS Trust during 2021/22.

"Never events are serious, largely preventable patient safety incidents that should not occur if existing national guidance or safety recommendations are in place," NHS England explained, and "may highlight potential weaknesses in how an organisation manages fundamental safety processes".

The East and North Herts NHS Trust, which runs Lister Hospital in Stevenage and the New QEII Hospital in Welwyn Garden City, said the wrong site treatments occurred in plastic surgery, radiology and ophthalmology, adding that "all areas have conducted a significant review and implemented changes to their procedures following these events".

It said "simulation training across theatres is planned in recognition of the human factors influencing the never events that have occurred," and a survey has been sent to all theatre staff, exploring psychological safety. The results will be incorporated into monthly training sessions, the NHS trust said, and a Patient Safety Day on September 23 is also planned.

During 2021/22, the NHS trust formally declared 147 serious incidents - "a marked increase from the previous year, attributable to the hospital-onset and hospital-acquired Covid-19 cases being declared," the NHS trust explained. There was also an increase relating to falls.

Chief executive Adam Sewell-Jones said: "It’s important to recognise the impact the pandemic has had on quality performance – including on elements of patient safety, inpatient falls and the number of serious incidents reported."

Chief nurse Rachael Corser added: “Despite another challenging 12 months as we continue to manage the impact of the pandemic, we are pleased our staff continue to feel able to report patient safety incidents – particularly where there was no harm, but they identified a potential risk.

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“By advocating an open culture for our staff and patients to report incidents, and by providing our staff with regular ways to learn from those which have taken place, we continue to improve the quality of care we provide.”