More needs to be done to learn from medical 'never events' – Shropshire health chief
More needs to be done to learn from medical 'never events' at the trust running Shropshire's main hospitals, health chiefs have said.
Four such events have been recorded by Shrewsbury and Telford Hospital NHS Trust (SaTH) since February.
They have involved the administration of a medicine by the wrong route and 'wrong site' surgery.
Never events are named so because they are incidents that guidelines say should never happen.
SaTH's quality and safety assurance committee has been looking at what actions have been taken since the incidents were recorded.
But a new report to SaTH's board by Dr David Lee, committee chairman, says more needs to be done to address issues.
It said: "Despite significant work to understand and address the problems within the operating theatres that have contributed to recent never events, there remains much to do.
"The committee is not yet assured that appropriate changes in culture and process have been achieved and will continue to seek evidence of on-going actions and improvement.
"The committee was clear that, where there are behavioural issues that mitigate against the implementation of safe practice, these must be addressed.
"At the August meeting the trust medical director indicated that he still could not be assured that the necessary cultural and behavioural changes have been made.
Wrong route
"Key elements of the surgical never events have been characterised by the procedure being minor and known safety checks having been bypassed."
A 'never event' in July happened in the emergency department at Royal Shrewsbury Hospital and related to the administration of a medicine by the wrong route.
It was the latest in a series of recent never events at the trust.
In June, a never event happened in an operating theatre at Telford’s Princess Royal Hospital.
It involved a 'retained swab' during an ear, nose and throat procedure, but the trust said no harm was caused to the patient.
A never event recorded by the trust in May involved 'wrong site' surgery.
There was a further never event at the trust earlier this year.
A never event recorded in February was to do with the administration of oramorph – a medication that should be taken orally but was given through the IV route.
Last October there was also a never event 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.
