57 hospi­tal blun­ders re­ported in two months

Western Mail - - NEWS - MATT DISCOMBE Lo­cal democ­racy re­porter matt.discombe@waleson­line.co.uk

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.”

> ‘Guid­ance from NHS Eng­land for in­va­sive pro­ce­dures is be­ing con­sid­ered in den­tal set­tings’

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