Patient name mix-up led to potentially fatal eye injections
A HOSPITAL patient was accidentally given four potentially fatal injections in his eyes after a blunder involving two people with the same name.
The so-called ‘never event’ took place at Birmingham and Midlands Eye Centre based at City Hospital.
An investigation found that two outpatients had been mixed up at their appointments because they had ‘similar names and dates of birth’. Staff failed to properly identify ‘Patient 1’ who stood up and went to consultation room when ‘Patient 2’s’ name was called.
Patient 1 was then mistakenly given two Lucentis injections in each eye – a drug that slows the growth of blood vessels.
Side-effects can include bleeding from the eye, cataracts and detached retinas. In the most serious cases the drug’s website warns of fatal complications related to blood clots, such as heart attacks and strokes.
Meanwhile, Patient 2 was given a series of tests, all of which were totally unnecessary.
It wasn’t until the patient asked a nurse when he would be getting his eye injections at 5.30pm that the blunder was uncovered.
A report into the incident stated: “When the error was discovered Patient 1 was recalled and asked to attend an urgent appointment with the consultant on November 4, 2016 to check for any adverse effects.
“An apology was given and the patient was asked to return in five days’ time on November 9, 2016.
“During the appointment on November 9 a letter of apology was also given to the patient by the con- sultant. There was no actual harm to the patient and nothing adverse was detected, however, the patient did state that he was experiencing a pulling sensation in his eyes.”
Sandwell and West Birmingham NHS Trust have now agreed new policies to ensure the mistake is not repeated.
They include issuing wristbands to patients who are having invasive procedures, and creating a separate area in the waiting room for people having injections.
Dr Roger Stedman, medical director said: “On November 3 a patient at our eye hospital was given the wrong treatment due to a failure to follow our patient identification procedure. The incident was discovered quickly and we apologised to the patient, and reviewed them to ensure no harm resulted from the treatment.
“We take patient safety very seriously and following this incident we reinforced the importance of our patient identification procedures to staff and we make sure that patients who are due to undergo invasive treatment are issued with a patient identification wristband at clinic registration.”