OBJECTS were twice left inside the bodies of patients after surgery at Coventry’s university hospital trust – a report has revealed.
They were among five serious incidents in the last six months.
Another of the five cases involved surgery being carried out in the wrong area while there were two cases of medicine being administered via the ‘wrong route’.
The University Hospital Coventry and Warwickshire Trust (UHCWT) Board reported five ‘never-events’ since December – the worst NHS category.
The hospital defines these as ‘serious incidents that are wholly preventable’ and are part of national guidelines aimed at preventing medical misconduct of this kind.
Only one of the reported incidents caused harm to the patient.
The more serious incident involved a colorectal swab being left inside a patient after colon surgery which prompted a follow-up procedure to retrieve the item.
A trust spokesperson said: “The patient required a minor interventional procedure to remove the swab.
“Due to the need for a procedure, this is graded as ‘moderate harm’ using national definitions, however there was no lasting physical damage to the patient.”
The report contains no further detail of the other incident of ‘a retained foreign object’ left in a patient’s body.
The trust says it has improved the process for reporting serious incidents and undertakes full Route Cause Analysis (RCA) of each incident.
The analysis is referred to the Serious Incident Group (SIG) – awhich meets weekly – and the chief executive officer.
This enables an action plan to be developed, addressing the recommendations, which are then carefully monitored to prevent recurrence.
A trust spokesperson said: “On each occasion we have discussed the error with the patient involved and/or their next of kin and offered to share the results of our investigations.
“The investigations were each led by a senior clinician using RCA methodology.
“RCA reports are scrutinised by our SIG to ensure that all aspects are considered and that the associated action plans are robust.”
UHCW have promised improvements and says it is analysing the circumstances and teaching about factors that lead to these mistakes.
They have also instated a Rapid Process Improvement Workshop which is intended to improve the reporting and investigation process of incidents.
It will also establish a Patient Safety Response Team (PSRT) to provide support for staff and patients when serious incidents occur – it will become fully functional this year.
The trust spokesperson added: “We have implemented a PSRT in critical care to provide immediate support following an incident with the intention of rolling this out across the trust in 2017/18.
“The PSR team consists of a senior doctor, senior nurse and patient safety officer who attend to the area where a serious incident has occurred.”
