Where medical errors are concerned, what would in other walks of life seem like trivial mistakes may have devastating consequences for patients and their families.
Operating on or treating the wrong limbs or organs should not happen and the expression used to describe such unacceptable and avoidable occurrences is ‘never events’. Yet eliminating all these events seems to be something likely to exist only in a medical ‘never-never land’. Just published information about never events occurring in recent months showed that East and North Hertfordshire NHS Trust had seen three such events, second only to the seven recorded by Barts Health NHS Trust in London, whose hospitals include St Bartholomew’s and Whipps Cross.
The Herts-based Trust – which is responsible for hospitals in Welwyn, Stevenage and Hertford, plus the Mount Vernon Cancer Centre in Northwood (Middlesex) – said in response to publication of the details that it had acted correctly in reporting the never events. A spokesperson for the Trust added that none of the three patients affected had suffered serious consequences.
In one of the Trust’s cases, hand surgery was initially started on the wrong finger. This error was quickly noticed at the time, before it was too late to avoid damaging the wrong finger and divert the procedure to the correct one. The Trust later said that steps had been taken, through training, to deal with human factors that could on rare occasions let such errors slip through.
Never events can take other forms and one that requires constant attention is the risk of serious errors in administering medication. There was one such case in the Trust’s three reported events, where medicine was given incorrectly. The other case involved failure to remove a vaginal swab.
Madeline Seibert, head of the medical negligence department at our firm, comments: “The fact that no patient suffered serious effects was indeed fortunate, as the potential for serious consequences was there in each case. It was indeed right for the Trust to identify these as never events, make formal reports and take action to avoid repetition and raise awareness of how even the most basic errors may have dire results.”