Theatre posters warn surgeons to check they have the right patient

HOSPITALS have put up posters in operating theatres reminding surgeons to ensure they are working on the right patient.

Oxford University Hospitals NHS Foundation Trust introduced the posters at John Radcliffe and Churchill hospitals after four patients underwent the wrong operations in May and June.

Known as “never events”, health bosses apologised for the errors, which included the wrong patient receiving an endoscopy, a procedure where a thin tube fitted with a camera is run through the body via the throat.

Managers at the trust, who also plan to introduce specialist staff training to tackle the issue, said the number of errors showed no sign of decreasing.

Tony Berendt, the trust medical director, said: “I know that the teams that have been involved in these events are deeply upset about what has happened. On behalf of those clinicians, I would extend my apologies to all patients involved and our public for the inevitable impact on their confidence in our services that these kind of events lead to.”

NHS England defines “never events” as “largely preventable” incidents that should not occur if guidance and safety recommendations are followed. There have been 181 cases in its hospitals in 2018 alone, including patients wrongly receiving laser eye surgery, ovary removals and bowel examinations.

The number of “never events” in England failed to decline from 2016 to 2017, with 466 and 467 recorded in each year, respectively. Situations where patients are left with medical equipment in their body after an operation or overdosed on the wrong drugs also fall within the category.

Kate Andrews, of the Institute of Economic Affairs, said: “It’s welcoming to see Oxfordshire hospitals taking steps to deliver more specialist staff training, to ensure that these kinds of ‘never events’ are better avoided. But the fact that such clinical mistakes are considered ‘largely preventable’ should be cause for alarm for the system as a whole.

“Substantial reform of the system … would likely reduce the number of ‘never events’ that occur each year. Sadly, with no meaningful plans for reform on the agenda, completely unnecessary – and largely frightening – errors like this continue to occur.”

Dr Kathy Mclean, the NHS Improvement executive medical director, said: “It is important that staff continue to be open and honest when things go wrong. It is not possible to compare the number of ‘never events’ on an annual basis because the … policy and framework and the ‘never events’ list are regularly revised as clinical practice changes. When reporting incidents, we expect hospitals to investigate and take action to improve safety and reduce the risks of them being repeated.”