Three “never events” occurred in hospitals under the Betsi Cadwaladr health board area in February. The incidents included the insertion of a contraceptive coil into a woman who had undergone a caesarean section, amputation of an incorrect toe during surgery and improper medication administration. According to NHS Wales, a never event refers to a serious patient safety incident that could have been prevented if proper measures were taken. The Health Board meeting on Thursday will discuss these events, although no information about the patients or hospitals involved has been disclosed.
The health board reported that a contraceptive coil, designated for another patient, was wrongly inserted in a postpartum woman who underwent a C-section. It occurred after the “list order was changed due to the increase in category for this patient”. The second never event identified in the report was “wrong site surgery” in which a patient was supposed to undergo toe amputation on the second and third toes, but an incision was made in the fourth toe instead. The error was detected, and the correct toes were eventually amputated.
The third incident was a “wrong route,” where a patient who couldn’t swallow medication was unintentionally given it intravenously. Live data shows that from April 2021 to March 2022, 37 never events have been reported in hospitals in Wales, with Betsi Cadwaldr health board accounting for twelve, and Aneurin Bevan and Hywel Dda health board reporting ten and none, respectively.
The Welsh government’s Deputy Chief Medical Officer, Chris Jones, said that never events show potential weaknesses in how a hospital manages its fundamental safety processes. Proper identification and full investigation of the incidents is necessary, said Jones. The Three never events will be discussed at Thursday’s health board meeting, during which an official statement is expected
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