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N&N op to fit artificial body part halted

PUBLISHED: 11:00 25 March 2010 | UPDATED: 09:07 02 July 2010

Staff at the N&N have been told to carry out extra checks after a limb went missing

Staff at the N&N have been told to carry out extra checks after a limb went missing

Sarah Brealey

Surgical staff at Norwich's main hospital are being told to make sure they check everything before surgery after an anaesthetised patient had to be woken up because vital equipment was missing.

Sarah Brealey

Surgical staff at Norwich's main hospital are being told to make sure they check everything before surgery after an anaesthetised patient had to be woken up because vital equipment was missing.

The incident at the Norfolk and Norwich University Hospital last month happened just before an operation to fit a prosthesis, or artificial body part. The patient had already been put to sleep when staff realised that the prosthesis was not there.

Hospital staff say they have learned from the experience and all surgical staff are being told to make sure that they carry out a pre-surgical checklist - similar in principle pre-flight checks carried out for aircraft - before patients are put to sleep.

Chief executive Anna Dugdale told yesterday's council of governors meeting: “The patient could have been harmed because they were anaesthetised and had to be woken up because the operation could not proceed. The patient did not come to any harm.

“We have learned from this and we have asked anaesthetists to use the surgical safety checklist before the patient is put to sleep. It was already happening, but sometimes after the patient was asleep, which is slightly missing the point.”

She said that while some were doing so, other surgeons were reluctant to use the checklist, or were not filling in the paperwork to show that they are using it. So this month the hospital is publishing an internal “league table” of surgeons who use the checklist, to try to appeal to their competitive instincts.

Staff governor Jacinta Bidewell, a physiotherapist, questioned why the league table was necessary and said all staff should be following “quite a basic safety measure”.

Mrs Dugdale said it was “a big cultural change” and added: “We are requiring it to be done by everybody, but not everybody is complying.”

The missing prosthesis was the only thing classed as a “serious untoward incident” at the N&N in the last four months. The hospital is trying to encourage staff to report these and more minor incidents, and hospital chairman David Prior said they wanted “a culture of openness” rather than staff being frightened to report them.

Have you had an operation that went wrong? Contact Evening News reporter Sarah Brealey on 01603 772485 or email sarah.brealey@archant.co.uk.

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