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When my little boy was 2 he was standing in the front door way, with his hand on the frame when a gust of wind blew the door shut, not only trapping his hand in the frame but cutting off the top of his finger. He was blue lighted to hospital and we were told they’d sew the finger back on the next day.
In preparation for the operation they put marker pen on the hand with this missing finger, explaining it was hospital procedure to ensure the surgeon operated on the correct hand.
I remember thinking at the time, how worrying it was that the black pen mark would provide more of a clue as to the afflicted digit than the missing fingertip.
However, mistakes do happen and it's not unheard of for surgeons to operate on the wrong part of the body... or even the wrong person altogether. Referred to as “never events” such occurances are regarded by the Government as clinical negligence so serious they "should never happen".
In the 6 months from April to September last year 148 of them occurred, out of these 37 were patients who had the wrong part of their body operated on.
The figures, released by NHS England, also show 69 cases where foreign objects were left inside patients, including 11 cases of surgical swabs, three cases where specimen retrieval bags were left inside, one patient who had wires left inside and another who was left with a needle in their body.
Of the 37 patients who had the wrong part of their body operated on or treated, one patient had the wrong toe removed, another received surgery on their left foot for a condition affecting their right foot and a patient also had an injection in the wrong eye.
Other never events shown in the report include a woman having her fallopian tube removed instead of her appendix, the wrong patient undergoing a heart procedure, and one patient undergoing surgery intended for someone else "due to incorrect results filed in notes".
December’s six-monthly figures are broadly comparable to 2012’s figures. In the previous 12 months, there were 325 never events, suggesting 2013's number could be similar.
While NHS England have said the overall incidence rate is less than 0.005%, or one never event in every 20,000 NHS procedures, no-one is claiming this is an acceptable figure. Professor Norman Williams, president of the Royal College of Surgeons and, together with NHS England, part of a taskforce which will look at ways to put an end to such errors, said “
However rare these incidents are, we believe never should mean never and avoiding such errors should be the priority of every surgeon”.
The release of the figures has been hailed as “a real step forward” by Health Secretary Jeremy Hunt, who also said: "We are determined to see the NHS become a world leader in patient safety - with a safety ethos and level of transparency that matches the airline industry.
"We want the NHS to be more transparent than ever when it comes to safety. I expect hospitals to examine these figures closely and take action to make the right improvements."
For the first time provisional quarterly data on the number of never events happening at each hospital trust in England will be published, for patients, healthcare professionals, managers, stakeholders and the public to see and understand. Previously data had only been published annually, and only at national, aggregated level. The data is available on the NHS England website, and from April 2014 it will be updated every month.
Dr Mike Durkin, national director of patient safety at NHS England, said:
"Awareness in the NHS of these issues has never been greater and the quality of our surgical procedures has never been better. It follows that the risk of these things happening has never been smaller.
Every single never event puts patients at risk of harm which is avoidable. People who suffer severe harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS.
But is time for some real openness and honesty. There are risks involved with all types of healthcare and one of those risks - with the best will in the world and the best doctors, nurses and other healthcare professionals in the world - is that things can go wrong and mistakes can be made. This has always been the case, and it is true everywhere in the world."
As I’ve said before, I’m a big believer in the NHS, in 2010 the Commonwealth Fund declared that in comparison with the healthcare systems of six other countries (Australia, Canada, Germany, Netherlands, New Zealand and USA) the NHS was the second most impressive overall. The NHS was rated as the best system in terms of efficiency, effective care and cost-related problems. It was also ranked second for patient equality and safety. As Dr Durkin says, things can go wrong and mistakes can be made.
However we don’t believe that if a person’s standard of life is affected due an avoidable error that they should have suffer the consequences without any help or support.
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