Eight 'Never Events' reported at Royal Cornwall Hospitals
The Royal Cornwall Hospital Trust has admitted several serious errors in patient care in the past six months since April 2020.
The hospital's Chief Executive has confirmed there have been eight of the so-called 'never events'. In one, a heart patient was left with a piece of wire inside them. The hospital trust has apologised.
A Never Event is the "kind of mistake that should never happen" in the field of medical treatment. These are serious and usually preventable.
The Never Events at the Royal Cornwall Hospital Trust largely occurred when staff failed to adhere completely to the "Five Steps to Safer Surgery" checklist which is used in the hospital.
They include:
Retained swab
This happened to a patient at St Michael's Hospital who was undergoing breast surgery. It was a consequence of staff failing to follow the count process for swabs.
Dermatology procedures in which patients had the wrong lesions or moles removed.
A 39 cm length of guide wire was left inside a heart patient. It had broken off from a 190 cm wire and was not detected.
All such wires are now checked that they are complete once the procedure is over.
A patient having cataract surgery had an incorrect lens inserted.
The team did not notice that the wrong patient's name was on the information about the lens strength.
The Royal Cornwall Hospital NHS Trust has issued the following statement:
"We are very disappointed that we have had never events after 13 months of not having one.
"While a Never Event is exactly that and should never happen, unfortunately human error can occur. Through our teams embedding ways of working together, identifying when things go wrong and putting in place improvements, we are striving to become the safest hospital in the UK. This is a core part of us providing the best care to our people in Cornwall and Isles of Scilly.
"Whilst none of the Never Events resulted in long term harm to patients, it is absolutely right that we are open and transparent about them, particularly where they could suggest a need for national changes in practice.
"We realise that none of us are infallible but feel proud and encouraged that our staff are much more confident in reporting any incidents, so we can rigorously review what went wrong and, most importantly, learn and prevent them happening again and through that provide safe and effective care for patients."
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