57 hospital blunders reported in two months
ASCREW put in the wrong place and a root canal filling in the wrong tooth were among serious incidents recently recorded at Cardiff and Vale hospitals.
There were 57 serious incidents at hospitals across the region reported to the Welsh Government in March and April this year.
They include a patient who had root canal treatment to a lower right tooth instead of the lower left side, and another incident where a patient with multiple fractures had a screw inserted at the incorrect site.
The two incidents are being managed as “never events”, classed as serious, largely preventable and should not have happened.
A medication error involving the prescription and administration of methotrexate – a drug used to treat conditions such as cancer, Crohn’s disease and multiple sclerosis, as well as for ectopic pregnancies and medical abortions – is also being treated as a never event.
Serious incidents which were not never events, but still reported to Welsh Government, included 14 falls where patients suffered significant injury, and six unexpected deaths of patients known to mental health services, including addictions services.
The death of a patient is being investigated by the coroner following concerns about medication management by a community pharmacy, a report by Cardiff and Vale University Health Board says.
The three never events remain under investigation, the report says.
Guidance from NHS England for invasive procedures is being considered in dental settings to reduce the risk of never events. The health board is also considering an independent review of the dental never events.
In the year leading up to the end of March there were around 300 falls reported by Cardiff and Vale University Health Board.
But the majority of falls “continue to result in no significant injury to patients,” the report says.
Ruth Walker, executive nurse director at Cardiff and Vale UHB said: “In line with our duty of candour we report all serious incidents to Welsh Government, the public and to our board.
“Patients and their families are made aware of incidents and are kept informed during investigations and discussions with our clinical teams. All incidents are fully investigated and appropriate actions are taken to reduce the risk of recurrence in the future.
“This enables clinical boards and the corporate teams to identify areas of good practice, but also to identify emerging trends and issues that require action in order to improve safety and quality of services.”