Action after Shropshire health trust's second 'never event' error of 2018
A serious medical ‘never event’ happened last month at the trust which runs Shropshire’s two main hospitals.
The never event, named so because they are incidents that guidelines say should never happen, was recorded by Shrewsbury and Telford Hospital NHS Trust in February.
A report to the trust board, which met yesterday, said it was to do with the administration of oramorph – a medication that should be taken orally but was given through the IV route.
A report to the trust board said: "This brings the total number of never events in the trust in year to two.
"This has been reported appropriately and in line with our trust standing operating procedure and the investigation into this case has begun."
Deirdre Fowler, director of nursing and quality at the trust, told members of the board that remedial action had been taken to prevent a recurrence.
The trust said it could not comment any further due to the ongoing investigation.
The last never event recorded by the trust happened in October in ophthalmology, which deals with the diagnosis, treatment and prevention of diseases of the eye and visual system.
The incident involved a locum surgeon implanting the wrong lens on a patient following cataract surgery.
Chief executive of the trust, Simon Wight, said the locum involved had their contract “terminated immediately” as processes were not followed.
The trust, which runs Telford’s Princess Royal Hospital and Royal Shrewsbury Hospital, was contacted by the Healthcare Safety Investigation Branch as a result.
The Healthcare Safety Investigation Branch asked the trust to take part in a national review of never events, specifically around the incorrect insertion of intraocular lenses.
Dr Edwin Borman, medical director, said at the time that the impact on the patient had been “negligible”.
