independent

Friday 18 April 2014

Litany of surgical mistakes and near-misses revealed

HUNDREDS of patients have been the victims of surgical errors or near-misses, including wrong-site surgery in the past two years, an Irish Independent investigation reveals.

Among the near-misses and blunders were 62 cases where surgeons incorrectly "marked" the wrong part of a patient's body ahead of an operation.

The potentially life-threatening mistake was not noticed in three of these instances and the surgeon went on to carry out a procedure. Two of these cases are now the subject of medical negligence actions.

It is feared that swabs, medical devices, needles or other foreign bodies were left inside up to 400 patients after they were sewn up in the operating theatre.

Thirteen of these cases have resulted in claims against the State.

In more than 1,000 cases, surgeons used the wrong patient's medical records before or during an operation.

And 365 patients had an incorrect identity band attached or none at all.

Distracted

Details of the botched procedures emerged in data obtained by the Irish Independent from the State Claims Agency.

A spokesman said intravenous tubes accounted for most of the foreign bodies that may have been left inside patients.

"Some cases can relate to where the patient left the hospital without informing staff and still had the tube attached," he said.

Wrong-site surgery refers to procedures carried out on the wrong limb or organ – or even on the wrong person. The agency was unable to say which parts of the body the wrong-site surgery involved, but publicised cases have included the removal of the wrong kidney.

The spokesman said many of the reports of missing swabs, devices or needles were "no harm" events and were logged on the system because they could not be found after surgery.

Sean Tierney, professor of surgical informatics at the Royal College of Surgeons, said swabs or other foreign bodies could be left in the patient in difficult situations or when the surgeon was distracted.

Surgeons are taught how to build in safety checks at different stages before and after the patient goes under the knife.

A key safeguard is a surgical pause, when the operating team takes time out to verify the patient's identity, confirm the procedure to be performed and ensure that all required equipment is present before the surgery starts.

"Wrong-site surgery is not a common event but it does happen," said Prof Tierney.

He said doctors should follow a well-established surgical safety checklist. "It's impossible to rely on people not making mistakes. You want systems in place to prevent those mistakes leading to patient harm," he said.

Practising surgeons have to undergo 50 hours a year of ongoing education and training.

"I think we have a good safety culture in Ireland, but that is not to say it could not be improved," said Prof Tierney.

Surgical outcomes in general are getting better – for instance, cardiac bypass surgery has a mortality rate of less than 2pc.

Irish Independent

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