Derriford Hospital reports five serious patient mistakes
Derriford Hospital have revealed that their staff have reported five incidents, known as 'never events' (so-called because they are events that should never happen), that relate to surgery or other intervention to the wrong part of the body of patients. These have all been identified via an incident reporting system since November. A 'never event' is classified by the Department of Health as a serious, preventable incident.
Plymouth Hospitals Trust say that "although none of the patients involved has been seriously or permanently harmed as a result", they take "these incidents extremely seriously" and are "taking appropriate action to improve patient safety."
The Trust added: "In each instance, the patient involved is aware of the incident, has been offered an apology and will be involved in the full investigation.
"We investigate all never events and publish recommendations afterwards; we also report them to the Primary Care Trust, Strategic Health Authority and the Care Quality Commission who oversee the actions being put in place. All never events are also reported publicly via our Board and papers on our website.
"As some of the events are very recent, we are still investigating and only when we know what the contributory factors and root causes are in each case can we take action to try to prevent a similar occurrence in future."
The Trust's statement continues:
"In healthcare, an organisation that encourages staff to report incidents and works to create a learning culture is actually working towards better patient safety. The recently published Francis Report talked extensively about the importance of ensuring an open NHS culture.
"We want to continue to promote an open culture with regards to adverse incidents and actively encourage all of our staff and patients to report areas of concern because all of these will provide learning. This is a practice that must be continued, supported and encouraged.
"Where a serious incident has occurred, a full and frank investigation is conducted to identify all potential learning opportunities. Patients and families are asked to participate in this process and will often contribute to the investigation and design of solutions to prevent future incidents. Every never event has an associated safety improvement programme.
"Healthcare is complex and we have excellent staff but humans are liable to human error. Our staff are devastated when anything goes wrong because they come to work to help people and want to provide the highest standard of care every time. They would never wish to harm a patient. This is why we must design our systems and processes so that we don’t rely on the vigilance of individuals.
"As a result of the incidents that have occurred we have revised our theatre safety plan, embedding the lessons from what has happened recently to create a new plan to go forward.
Today's announcement follows previous criticism of the hospital. Back in 2011, a report by the Care Quality Commission warned Derriford it risked prosecution after six never events were reported in six months, four of which involved swabs being left in patients. The report was also critical of certain essential standards including working practices and safety check procedures. A subsequent inspection the same year reported "a real improvement" and "found clinical staff appeared to be more aware of the need to avoid serious preventable incidents."
The Trust moved to allay people's fears saying: "We perform 80,000 operations each year, some of them extremely complex and high-risk. We want to reassure anyone out there waiting to come in to be treated that the risk to them of something untoward happening is very, very small indeed.
"For every patient that is harmed, that is one patient too many. We are continuing to build on the work we have already done to improve patient safety. We have taken action to review our policy and remind all our staff of this and and their responsibilities."
