Swab Left Inside Patient After Charing Cross Operation
Trust makes changes to avoid similar 'Never Events' happening again
A 'foreign body' was left inside a patient after an operation at Charing Cross Hospital.
A swab was left inside a patient undergoing care in the ear, nose and throat department at the hospital in Fulham Palace Road, Hammersmith, in April.
The hospital is run by Imperial College healthcare NHS Trust. The case was revealed in the latest 'Never Event' reports which are published by the NHS.
That is the terminology used to describe medical errors. The Never Event data comes from NHS Improvement’s statistics for April to July.
Across the country there were 125 Never Events, which include 23 cases of “foreign bodies” left inside people after medical procedures, such as the one at Charing Cross Hospital.
An Imperial College Healthcare NHS Trust spokesman said: “We take ‘never events’ extremely seriously and recognise the impact they have on patients and staff.
“We investigate each case thoroughly and have put in place a comprehensive trust-wide action plan which includes an innovative coaching and simulation training programme for all staff involved in invasive procedures to help them continually improve.”
The trust is unable to provide more details of the incident, due to confidentiality issues.
But it said the team involved had coaching, a simulation training programme and a debrief session after the incident.
They’ve also looked at what they could alter to prevent it happening again.
The trust has changed to the use of throat packs which are coloured and have a tail when being intentionally retained and has undertaken direct communication to staff about the need to repeat the swab count and follow stricter guidelines about their use.
Olivia Clymer, the chief executive of patients’ watchdog Healthwatch Central West London, said: “NHS never events are always distressing for patients, their families and the NHS staff involved.
“What’s important for everyone is that there is a culture of openness and learning from mistakes."
Julia Gregory, Local Democracy Reporter
October 9, 2019