The Daily Telegraph (23 August 2009) carries an article on serious untoward incidents (SUIs) involving patient in the NHS. They allege that “last year there were a total of 336 serious incidents, 77 surgical mistakes, 41 equipment failures and a total of 218 drugs events. These include:
– Surgeons operated on the wrong patient after getting confused because two people with the same name were on the same ward
– Medics accidentally taking the eyes out of the wrong dead patient
– A woman who underwent surgery on her tearducts had the operation performed on the wrong eye while in a separate case a medic inserted the wrong lens during a cataract procedure
– Five times the correct dose of chemotherapy drug was given to a patient and an incorrect dose of ketamine led to a patient undergoing leg surgery suffering a heart attack
– Doctors had to remove a catheter from a patient’s leg artery after it snapped off inside him
– A patient who underwent a knee replacement had the wrong sized joint put in
– A patient who woke up from the operating theatre to find surgeons had ‘fixed’ the wrong kidney and he had to go back under the knife for the operation a second time”
Healthcare Governance Review recognises that that in the vast majority of cases, patients are treated without harm or dissatisfaction with care. However, in a small minority of instances, patients do suffer potentially preventable harm and/or dissatisfaction and ongoing improvement in the safety and quality of care should be underpinned by learning from things that have gone wrong.
The National Patient Safety Agency (NPSA) comes in for strong criticism in the article. According to the Daily Telegraph, “The National Patient Safety Agency costs 30 million a year, yet they have made no attempt to draw up reliable up to date figures. They admit that 7% of hospital trusts and 13% of primary care trusts report no incidents at all yet they take no action and patients continue to be put at risk.” Established in 2001, the NPSA has been widely criticised, including by the Public Accounts Committee, for failing to deliver a working national reporting and learning system for patient safety incidents in line with the Department of Health document Building a safer NHS for patients.
Read the Daily Telegraph article here.