Patient almost got knee replacement for wrong leg in 'never event' at South Tyneside Hospital
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According to the report for care bosses, doctors at South Tyneside Hospital only realised during surgery they were attempting to swap the left leg joint with a prosthetic intended for the right leg.
Fortunately however they noticed the error before they finished, meaning it could be corrected with ‘no further issues identified’.
The incident was given a ‘minor harm’ rating by managers and included on a list of three ‘never events’ currently being investigated at the newly formed South Tyneside and Sunderland NHS Foundation Trust (STSFT).
Also being probed is a so-called ‘wrong site surgery’ at Sunderland Royal Hospital, in April, in which a patient had an operation on the wrong leg.
In the third incident, also at Sunderland, in August in 2018, surgeons operating on a patient’s arm performed the procedure at the elbow, rather than at the wrist as originally planned, although more investigation is needed before it can also be classed as a ‘wrong site surgery’.
Details of the incidents were revealed in a report prepared for the Durham Dales, Easington and Sedgefield and North Durham Clinical Commissioning Groups (CCGs).
According to this, investigations are ongoing with updates due to be reported back through the CCGs’ serious incident panel.
Shaz Wahid, medical director at STSFT, said: “Providing safe, high quality care is one of our absolute priorities.
“No patient came to any serious harm in relation to the three never events and all have received a full apology.
“However, we recognise the need to embed a positive safety culture where everyone in the NHS feels able to learn and improve when things go wrong.
“Although never events are extremely rare and should never happen, there are risks associated with healthcare and we continue to raise awareness amongst our staff of the systems and safeguards we have in place to prevent similar events occurring again.”
According to national NHS figures, there were 496 ‘serious incidents’ which ‘appeared to meet the definition of a Never Event’ in 2018/19.