Revealed: The six 'never events' at Norfolk's hospitals since 2020
- Credit: Archant
An eye injection being administered to the wrong patient is among a series of 'never events' recorded at Norfolk's hospitals over the last two years.
'Never events' are defined by NHS England as serious patient safety incidents, but which are largely preventable if staff had followed guidelines.
Official data from Norfolk's three NHS foundation trusts shows that there were at least six recorded at their hospitals between April 2020 and October 2021. In total, there were 248 such incidents across the entire country during that period.
As well as the incorrect eye injection, other 'never events' to have occurred in Norfolk included medics accidentally leaving items behind in patients' bodies after medical procedures, people being given the wrong medicine and others being attached to the wrong treatment machines.
The Trusts all said they had investigated the incidents and taken steps to prevent them happening again.
The information comes from freedom of information (FoI) requests, as well as data released by NHS England. Norfolk's trusts responded differently to the FoI requests, so their responses correspond to slightly different time periods.
There were three 'never events' reported to Norfolk and Norwich University Hospitals NHS Foundation Trust from 2020 to 2021.
These included an incident of a patient "retaining a foreign object post-procedure" - in this case a cannula which was not removed - in December 2020.
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There were also two occasions when patients were unintentionally connected to an air flowmeter - which is used to administer medication - when they actually required oxygen.
According to NHS data, there were 80 incidents of foreign objects being retained post-procedure and 28 incidents of connecting patients to air flowmeters rather than oxygen in England from April 2020 to March 2021.
A spokesperson for the Foundation Trust said: “Following incidents where patients were given medical air instead of oxygen, nebulised medication is now administered via portable nebuliser machines using room air. We have also capped off medical air, which eliminates the risk of connecting a patient to the wrong gas and we have ensured that we are compliant with a recent National Patient Safety Alert.”
And in relation to the foreign object, the spokesman said: "We investigated and have apologised to a patient whose cannula was not fully removed following treatment. We have provided extra training in cannula care and monitoring to staff and regular training on ultrasound scanning following this incident."
There were two 'never events' reported to James Paget University Hospitals NHS Foundation Trust in 2021.
These two incidents both involved a patient retaining a foreign object post-procedure. Both occurred when the guidewire that is used to allow a patient’s nasogastric tube to be visible on x-ray was not removed when it should have been.
Nasogastric tubes are small tubes placed through the nose and end with the tip in the stomach. They can be used for feeding, medication administration, or removal of contents from the stomach.
According to NHS data, there were 10 cases of guidewires being retained post-procedure in England from April to October of this year.
A spokesperson for the Foundation Trust said: "Our procedures are aimed at preventing these events but should one occur, we carry out a full investigation to find out how and why it happened, to identify what can be learned and whether any procedural changes are required. In these two particular cases, no harm occurred to either patient and relevant guidance was re-circulated to staff.”
There was one "never event" reported to The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust in 2021.
In February, a patient was given an injection into the eye which was intended for another patient, during a clinic for a condition shared by both patients.
This is a procedure to place medication directly into the space in the back of the eye called the vitreous cavity.
The injection the patient received was a comparable treatment to that which they were intended to receive, and there was no harm to the patient.
Louise Notley, director of patient safety at the Foundation Trust, said: “Whilst we can’t comment in any more detail due to patient confidentiality, we are committed to providing safe and compassionate care for our patients and the Trust has made a number of system improvements to reduce the chance of adverse incidents.”