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Hospital trust reports two "never events" in one month

View profile for Judith Thomas-Whittingham
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The BBC has recently reported on the story of two “never events” occurring at the same hospital in Devon in June 2013.

According to the Department of Health, a “never event” is an incident that is so serious and preventable that they should never happen.

The “Never Events List” for 2012/13, produced by the Department of Health, lists 25 such errors, including surgery on the wrong part of the body, retained foreign objects (like surgical instruments) post-operation, incorrect administration of insulin and misidentification due to a failure to use the patient wristband process.

In June this year, in one incident at the Royal Devon and Exeter Hospital a patient was given the wrong blood type during a blood transfusion and in a second, separate incident, another patient had an unnecessary angiogram (where a tube is inserted into the arteries of the heart to inject a dye).

Both incidents are now being investigated, however it is not only Royal Devon and Exeter NHS Trust that has suffered “never events” in the last few years.

In May 2013, figures for the number of “never events” occurring at NHS Trusts across England between 2009 and 2012 were revealed, showing that more than 750 patients had experienced some kind of “never event”.  

The top four incidents by number of occurrences were retained foreign objects post-operation (322 incidents), wrong site surgery (214 incidents), misplaced nasal or oral feeding tubes (73 incidents) and the use of the wrong implant or prosthesis (58 incidents).

The number of incidents between 2009 and 2012 can be put into context when compared to the total number of patients that the NHS treated over the same period, which will run into millions. However, the fact that there were still over 750 such events, which by their very definition should never happen, is perhaps still cause for concern.